Professional Documents
Culture Documents
difficulty of
breathing in a
1 year and 2
month old, male
patient
Prepared by
Gardiola | Gepte | Gonzaga
General Data
JDB is a 1 year and 2 months old, male
Born September 13, 2015 at the OMMC
Filipino, Roman Catholic
Presently lives with both parents in San
Andres Bukid, Manila
First admission at OMMC at Nov 25, 2016
at 10:00AM.
Chief Complaint
Difficulty of breathing
REVIEW OF SYSTEMS
GENERAL
(-) weight loss/gain, (+) decrease in activity level
CUTANEOUS:
(-) rash, (-) change in skin color,
(-) pigmentation, (-) pruritus
HEENT
HEAD: (-) history of head trauma
EYES: (-) lacrimation (-) redness
REVIEW OF SYSTEMS
(continued)
EARS: (-) discharge
NOSE: (-) epistaxis
MOUTH and THROAT: (-) salivation, (-)
bleeding gums, (-) sore throat
CARDIOVASCULAR:
(-) orthopnea, (-) cyanosis
RESPIRATORY:
(-) hemoptysis, (+) coughing
REVIEW OF SYSTEMS
(continued)
GASTROINTESTINAL:
(-) vomiting, (-) diarrhea, (-)
constipation, (-) passage of worms, (-)
abdominal pain, (-) jaundice, (-)
appetite
GENITOURINARY:
(-) discharge, (-) edema of hands and
feet
REVIEW OF SYSTEMS
(continued)
ENDOCRINE:
(-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold/heat
intolerance
NERVOUS/BEHAVIORAL:
(-) tremors, (-) sleep problems, (-) convulsions
MUSCULOSKELETAL:
(-) limping, (-) stiffness
HEMATOPOIETIC:
(-) pallor, (-) bleeding, (-) easy bruising
PERSONAL HISTORY
GESTATIONAL HISTORY
18 y.o. mother during pregnancy
LMP at Dec 15, 2014
G1P1
Unremarkable health status during pregnancy
Intake of vitamins, ferrous sulfate, and folic acid
AOG at 36 weeks
PERSONAL HISTORY
GESTATIONAL HISTORY
Sought antenatal care at 4th, 6th, 7th
and 8th months
Consulted every other day before
delivery
PERSONAL HISTORY
(continued)
HISTORY OF BIRTH
Premature infant, delivered at 36
weeks
Delivered NSD at OMMC
Birth weight at 3.2 kg
Baby swallowed meconium
APGAR unrecalled
PERSONAL HISTORY
(continued)
NEONATAL HISTORY
Jaundice for 1 day
Underwent phototherapy on the 2nd
day
No cyanosis noted
Newborn screening performed
PERSONAL HISTORY
(continued)
NEONATAL HISTORY
Only 1 month of breastfeeding
Mother stopped breastfeeding the
patient when she caught the flu
Shift to formula feeding
Feeding History
Type of feeding: formula feeding
Breastfeeding was discontinued when
patient was 1 month old because his
mother caught the flu
Formula brand is Bonakid
Consumes about 6 bottles per day
Feeding History
(continued)
Complementary feeding started at 6
months
Macerated meat and vegetables,
Cerelac
Eats breakfast and dinner
Consumes rice, fruits, vegetables
Usual food intake: cereals, rice,
vegetables
Feeding History
(continued)
No food intolerance noted by the
patients parents
Vitamins and iron supplements not
given to child
Development and
Behavioral History
At 1 year and 2 months, the patient can:
Say mama and papa
Drink from a cup
Can hold a Stick-o and feed it to himself
Kisses on request
Releases objects on request
Obeys commands with gestures
Can verbalize and point to an object at a
distance
Past Illnesses
No history of mumps, measles, rubella,
or varicella
No previous hospitalizations
No previous surgeries
No allergies
No noted previous injuries
Family history
Parents are 20 y.o., both graduating
college students
Both are in good physical and mental
health
Caregiver when the patients parents
are away is the maternal grandmother
Patient is an only child
Family history
(continued)
No history of familial illness among
members of the household
No history of Diabetes Mellitus,
cardiovascular diseases, cancers,
hematologic disorders, allergy
Socio-economic history
The family lives in a structure shared with
3 other families.
House is made of wood
2 rooms in the house, total floor area is
about 40 sqm
Maternal grandmother lives with them
Source of household income is the
patients father
Environmental history
Houses in the neighborhood are closely
built
Presence of smokers in house
Garbage collected twice a week
Source of water is from Manila Water
Source of drinking water is the same as
water used for washing and bathing
PHYSICAL EXAMINATION
GENERAL SURVEY
Patient was conscious, calm and quietly
being carried by her mother.
Patient sometimes gets irritated.
He appears to be well-nourished, wellhydrated and looks appropriate to his age.
He is not in respiratory distress and no
signs of discomfort
PHYSICAL EXAMINATION
(continued)
VITAL STATISTICS
Temperature:
36.5 aural
43 bpm
115bpm
PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:
9.5kg
Length:
77cm
Head circumference:
Chest circumference:
Abdomen:
Arm circumference
45cm
46cm
40cm
14cm
PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:
9.5kg
Length:
77cm
Head circumference:
Chest circumference:
Abdomen:
Arm circumference
45cm
46cm
40cm
14cm
PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:
9.5kg
Length: 77cm
Body mass index 16.6
Head circumference: 45cm
Chest circumference: 46cm
Abdomen: 40cm
Arm circumference 14cm
PHYSICAL EXAMINATION
(continued)
GROWTH CHARTS
PHYSICAL EXAMINATION
(continued)
INTEGUMENTARY
Brown in color
PHYSICAL EXAMINATION
(continued)
HEAD
Head is normocephalic with no visible lumps
Hair was fine, black, and equally distributed.
There were no noted palpable depressions,
masses. No reported areas of tenderness
upon palpation
Posterior fontanel closed while still anterior
fontanel open
PHYSICAL EXAMINATION
(continued)
EYES: unremarkable
Eyebrows are symmetrically aligned, black, fine,
evenly distributed without scaliness.
Eyelids are symmetrical without any lesions.
No periorbital edema, ptosis or lid lag.
Palpebral conjunctivae pinkish without any
discharge.
Sclerae were anicteric; cornea clear.
Pupils are equally reactive to light.
PHYSICAL EXAMINATION
(continued)
EARS: Unremarkable
PHYSICAL EXAMINATION
(continued)
NOSE AND SINUSES: Unremarkable
Nose appears symmetric with no
deformities, swelling and lesions.
Pink mucosa
Midline septum
Nasal discharge was noted
PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.
PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.
PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.
PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.
PHYSICAL EXAMINATION
(continued)
NECK: Unremarkable
Neck was symmetrical no lesions and no
palpable lymph nodes.
No jugular vein distention.
Trachea is at midline.
No bruits heard upon auscultation.
Thyroid gland not palpable.
PHYSICAL EXAMINATION
(continued)
CHEST AND LUNGS:
Chest circumference larger than the head
circumference
AP diameter of the chest is equal to the
transverse diameter
No chest retractions observed during
examination
Chest expansion is symmetrical
PHYSICAL EXAMINATION
(continued)
CHEST AND LUNGS:
Resonant upper lung fields
Bilaterally decreased breath sounds
Bilateral coarse crackles on lower
anterior lung fields
PHYSICAL EXAMINATION
(continued)
CHEST AND HEART:
Adynamic precordium with PMI approximately
1cm noted to be at the 4th LICS midclavicular,
approximately 1 cm in diameter.
No heaves or thrills.
Distinct S1 and S2 heart sounds. S1>S2 at
the apex and S2>S1 at the apex.
No murmurs heard
PHYSICAL EXAMINATION
(continued)
ABDOMEN: Unremarkable
Abdomen is slightly globular.
Skin has no dilated veins, striae, and visible
masses.
Umbilicus inverted.
Bowel sounds normoactive with 11 per
minute (RLQ)
No bruit heard on the abdominal aorta.
PHYSICAL EXAMINATION
(continued)
ABDOMEN: Unremarkable
Abdomen was soft, without muscle
guarding and tenderness upon palpation.
Liver, spleen and kidneys are not
palpable.
Abdomen was tympanitic
PHYSICAL EXAMINATION
(continued)
EXTREMITIES
Upper and lower extremities appear
proportional.
Nailbeds are pinkish.
No swelling, deformities, redness,
ecchymoses or edema.
Capillary refill time is <2seconds
Neurologic examination
GENERAL EXAMINATION
Patient is alert, awake, cooperative but
sometimes gets irritated and cries.
Not in respiratory distress and does not use
accessory muscles when breathing.
Responds to social overtures.
No unusual facies and gross structural
abnormalities noted.
Neurologic examination
GENERAL EXAMINATION
Patient is alert, awake, cooperative but
sometimes gets irritated and cries.
Not in respiratory distress and does not use
accessory muscles when breathing.
Responds to social overtures.
No unusual facies and gross structural
abnormalities noted.
Neurologic examination
MOTOR EXAMINATION
Symmetrical muscle bulk and spontaneous
muscle movements against gravity are
observed.
Muscle tone is good without spasticity or
flaccidity.
No tremors, tics, involuntary movements and
spasm noted.
SALIENT FEATURES
Difficulty of
Breathing
Pulmonar
y
Extra pulmonary
Cardiac
Cardiac
findings:
(-)
orthopnea
(-) cyanosis
More pa
Musculoskeletal
RULED
OUT
MSK findings:
Muscle
retractions
More pa
Pulmonar
y
Suprastern
al
retractions
Upper
Airway
Pathology
Respiratory
distress
Stridor
WHO criteria
for pneumonia
Fever
Tachypnea
Cough
RULED
OUT
Restricti
ve
Pathology in
the lung
parenchyma
Lower
Respiratory
Tract Diseases
Croup
Pneumonia
Bacterial
Viral
Aspiration
Tuberculosis
CANNOT BE
RULED OUT