I. DEMOGRAPHIC DATA .
FULL NAME:
ADDRESS:
CIVIL STATUS: Child
BIRTHDAY: April 16, 2010
BIRTHPLACE: Benguet General Hospital
NATIONALITY: Filipino
RELIGION: Roman Catholic
EDUCATIONAL ATTAINMENT: n/a
AGE: 2/12 mo
GENDER: female
FATHER:
OCCUPATION: conductor
AGE: 25
MOTHER:
OCCUPATION: housewife
AGE: 22
SIBLINGS:
ADMISSION DETAILS
DATE ADMITTED: June 19, 2010
TIME ADMITTED: 9:45 am
WARD: Pediatric Ward, PO1
CHIEF COMPLAINT: cough and colds for 1 week
ADMITTING DIAGNOSIS: Pneumonia, Congenital Heart Disease, Cyanotic
PEDIATRICIAN:
ROTATION DETAILS
CLINICAL INSTRUCTOR:
WARD: Pediatric Ward, BeGH
DATE: June 20, 2010
, II. HEALTH HISTORY
A. History of Present Illness
Client’s condition started 2 weeks prior to admission. The client’s mother noticed that her
daughter had been having bouts of productive cough. The child was given a concoction from boiled
oregano leaves for 2 days before her mother decided to consult doctors from Epiphany, a private
clinic at Km.6 La Trinidad, Benguet. The client was seen and the doctor prescribed a mucolytic and
antibiotic which was to be taken for 5 days and 7 days respectively. The mother only gave the
medicines for 4 days because she did not notice any effects.
1 day PTA, the client was brought back to Epiphany for a follow-up check-up. Because of the
child’s worsened condition, the patient was refered to BeGH for admission.
B. Past Medical History
The client’s mother claimed that the child was healthy up until 2 weeks ago, when the cough and
colds started. The client’s mother also stated that the child was healthy when she was born and that
doctors did not inform her of possible defects. Although, the client was born almost a month before
her mother’s expected date of confinement (May 1, 2010).
C. Socio-Cultural History
Although the client is still quite young for this to be assessed, she would be raised under the
influence of her parents’ cultures and as a Roman Catholic. Client also lives in a home shared with
her sibling and parents. The client’s mother stated that only their family live in their home.
D. Heredofamilial History
The client’s mother stated that she and her husband had no hereditary diseases that the child
may have acquired. However, the child’s grandmother – from the mother’s side – was diagnosed
with hypertension. Her grandfather – also from the mother side – had a history of kidney disease,
although her mother did not specify what. No diseases from the father’s side were made mention.
E. Pediatric History
The client was born on April 16, 2010 despite her mother’s EDC being on May 1, 2010 based on
her ultrasound results. At birth, the client weighed 2.57 kg and anthropometric measurements were
unrecalled. The mother said the baby had a good cry. At present, the child weighs 4 kg. Her
anthropometric measurements are: HC = 38 cm; CC = 37.5 cm; AC = 11 cm. The client’s mother
stated that the child had been healthy up until 2 weeks PTA.
The client’s mother stated that she did not have any history of smoking and drinking of alcoholic
substances both before and during her pregnancy. She recalls having cough and colds during her
pregnancy but did not take any medications. She also does not recall being exposed to any
teratogenic materials that may have caused the congenital heart disease of the patient.
, III. 13 AREAS OF ASSESSMENT
I. PSYCHOSOCIAL STATUS
The client is the 2nd child of Mr. and Mrs. Ernest Tiongco of Bayabas, Pico, La Trinidad, Benguet.
She was born on April 16, 2010 at BeGH. She is still unbaptized but her parents are both Roman
Catholics. Her father works as a conductor while her mother stays at home and watches over the
children. Her sibling, Jesse, is 2 years old.
At this age, the child is believed to belong at the “trust versus mistrust” stage of Erik Erikson’s
Social Development theory. Hence infantile needs must be met at once upon demand. This means
that the client is completely dependent on her parents, specially her mother, for her survival. It is her
mother who spends the most time with her. Her activities are mostly limited to basic survival
instincts such as eating, eliminating body wastes and sleeping. The child’s fears may be evident as
well when she exhibits a reflexive startle response to loud noises and sudden movement sin the
environment (Muscari, 2005).
Although the client is already the 2 nd child of the family, the mother stated that she was not a
planned baby. However, the client’s parents are still supportive of the well being of their daughter.
II.MENTAL AND EMOTIONAL STATUS
During this age, the client is believed to belong to the sensorimotor stage of development. It is
where she uses the senses, particularly through sucking and grasping, that the child gains knowledge
of the environment. This is also the reason why a positive grasping reflex was seen upon assessment
of the patient.
The client’s current means of communication is through crying, which is said to be successfully
differentiated by the patient’s parents. This is true to the patient upon assessment. Client is also
already able to coo.
III. ENVIRONMENTAL STATUS
Before hospitalization, the client lives with her parents and sibling in their home in La Trinidad.
Her mother stated that despite their humble abode, they still try to provide a safe environment for
the patient. During hospitalization, the child stays in the pediatric ward where beds are at least 3
feet apart from one another. The beds have no side rails hence making the child prone to falls. Still,
the client’s mother attempts to keep her baby warm by covering her in the appropriate clothes and
blankets.
The client’s bed is near a window hence ventilation and lighting are not a problem. However,
upon interview, the outside rain creates a cold atmosphere that may not be comfortable to the baby.
Although the client is not isolated from other patients, there are no other patients with
infectious diseases within the proximity. Also, the client’s mother stated that at home, the family
members were all healthy; hence she could not have acquired the infection from their home.
IV. SENSORY STATUS
Although this part can not be assessed well because of the patient’s inability to respond, the
client is seen with various evidences of sensory intactness. The patient is able to respond to voices
which show the ability to hear. Client may also focus her stare on something of interest to her. Lastly,
the patient may cry when painful stimuli is introduced, hence showing intact tactile ability.
Client’s physical features were normal. Her ears were symmetrical and so were her upper and
lower extremities. Her sclera however appeared to be jaundiced despite her skin being of normal
color.
V.MOTOR STATUS
The client is able to turn her head from side to side when in a prone position. This is basic to
infants of her age. The client is also already able to have a good grasp when an object is placed on
her palm. Those are the gross motor and fine motor skills that she can perform respectively.
VI. NUTRITIONAL STATUS
The client’s mother stated that she was purely breast fed since birth. The only exception was
when they tried to give her the concoction of boiled oregano leaves to help alleviate her cough and
colds. Her mother stated that the client was breastfed around 5 times per day, depending on the
FULL NAME:
ADDRESS:
CIVIL STATUS: Child
BIRTHDAY: April 16, 2010
BIRTHPLACE: Benguet General Hospital
NATIONALITY: Filipino
RELIGION: Roman Catholic
EDUCATIONAL ATTAINMENT: n/a
AGE: 2/12 mo
GENDER: female
FATHER:
OCCUPATION: conductor
AGE: 25
MOTHER:
OCCUPATION: housewife
AGE: 22
SIBLINGS:
ADMISSION DETAILS
DATE ADMITTED: June 19, 2010
TIME ADMITTED: 9:45 am
WARD: Pediatric Ward, PO1
CHIEF COMPLAINT: cough and colds for 1 week
ADMITTING DIAGNOSIS: Pneumonia, Congenital Heart Disease, Cyanotic
PEDIATRICIAN:
ROTATION DETAILS
CLINICAL INSTRUCTOR:
WARD: Pediatric Ward, BeGH
DATE: June 20, 2010
, II. HEALTH HISTORY
A. History of Present Illness
Client’s condition started 2 weeks prior to admission. The client’s mother noticed that her
daughter had been having bouts of productive cough. The child was given a concoction from boiled
oregano leaves for 2 days before her mother decided to consult doctors from Epiphany, a private
clinic at Km.6 La Trinidad, Benguet. The client was seen and the doctor prescribed a mucolytic and
antibiotic which was to be taken for 5 days and 7 days respectively. The mother only gave the
medicines for 4 days because she did not notice any effects.
1 day PTA, the client was brought back to Epiphany for a follow-up check-up. Because of the
child’s worsened condition, the patient was refered to BeGH for admission.
B. Past Medical History
The client’s mother claimed that the child was healthy up until 2 weeks ago, when the cough and
colds started. The client’s mother also stated that the child was healthy when she was born and that
doctors did not inform her of possible defects. Although, the client was born almost a month before
her mother’s expected date of confinement (May 1, 2010).
C. Socio-Cultural History
Although the client is still quite young for this to be assessed, she would be raised under the
influence of her parents’ cultures and as a Roman Catholic. Client also lives in a home shared with
her sibling and parents. The client’s mother stated that only their family live in their home.
D. Heredofamilial History
The client’s mother stated that she and her husband had no hereditary diseases that the child
may have acquired. However, the child’s grandmother – from the mother’s side – was diagnosed
with hypertension. Her grandfather – also from the mother side – had a history of kidney disease,
although her mother did not specify what. No diseases from the father’s side were made mention.
E. Pediatric History
The client was born on April 16, 2010 despite her mother’s EDC being on May 1, 2010 based on
her ultrasound results. At birth, the client weighed 2.57 kg and anthropometric measurements were
unrecalled. The mother said the baby had a good cry. At present, the child weighs 4 kg. Her
anthropometric measurements are: HC = 38 cm; CC = 37.5 cm; AC = 11 cm. The client’s mother
stated that the child had been healthy up until 2 weeks PTA.
The client’s mother stated that she did not have any history of smoking and drinking of alcoholic
substances both before and during her pregnancy. She recalls having cough and colds during her
pregnancy but did not take any medications. She also does not recall being exposed to any
teratogenic materials that may have caused the congenital heart disease of the patient.
, III. 13 AREAS OF ASSESSMENT
I. PSYCHOSOCIAL STATUS
The client is the 2nd child of Mr. and Mrs. Ernest Tiongco of Bayabas, Pico, La Trinidad, Benguet.
She was born on April 16, 2010 at BeGH. She is still unbaptized but her parents are both Roman
Catholics. Her father works as a conductor while her mother stays at home and watches over the
children. Her sibling, Jesse, is 2 years old.
At this age, the child is believed to belong at the “trust versus mistrust” stage of Erik Erikson’s
Social Development theory. Hence infantile needs must be met at once upon demand. This means
that the client is completely dependent on her parents, specially her mother, for her survival. It is her
mother who spends the most time with her. Her activities are mostly limited to basic survival
instincts such as eating, eliminating body wastes and sleeping. The child’s fears may be evident as
well when she exhibits a reflexive startle response to loud noises and sudden movement sin the
environment (Muscari, 2005).
Although the client is already the 2 nd child of the family, the mother stated that she was not a
planned baby. However, the client’s parents are still supportive of the well being of their daughter.
II.MENTAL AND EMOTIONAL STATUS
During this age, the client is believed to belong to the sensorimotor stage of development. It is
where she uses the senses, particularly through sucking and grasping, that the child gains knowledge
of the environment. This is also the reason why a positive grasping reflex was seen upon assessment
of the patient.
The client’s current means of communication is through crying, which is said to be successfully
differentiated by the patient’s parents. This is true to the patient upon assessment. Client is also
already able to coo.
III. ENVIRONMENTAL STATUS
Before hospitalization, the client lives with her parents and sibling in their home in La Trinidad.
Her mother stated that despite their humble abode, they still try to provide a safe environment for
the patient. During hospitalization, the child stays in the pediatric ward where beds are at least 3
feet apart from one another. The beds have no side rails hence making the child prone to falls. Still,
the client’s mother attempts to keep her baby warm by covering her in the appropriate clothes and
blankets.
The client’s bed is near a window hence ventilation and lighting are not a problem. However,
upon interview, the outside rain creates a cold atmosphere that may not be comfortable to the baby.
Although the client is not isolated from other patients, there are no other patients with
infectious diseases within the proximity. Also, the client’s mother stated that at home, the family
members were all healthy; hence she could not have acquired the infection from their home.
IV. SENSORY STATUS
Although this part can not be assessed well because of the patient’s inability to respond, the
client is seen with various evidences of sensory intactness. The patient is able to respond to voices
which show the ability to hear. Client may also focus her stare on something of interest to her. Lastly,
the patient may cry when painful stimuli is introduced, hence showing intact tactile ability.
Client’s physical features were normal. Her ears were symmetrical and so were her upper and
lower extremities. Her sclera however appeared to be jaundiced despite her skin being of normal
color.
V.MOTOR STATUS
The client is able to turn her head from side to side when in a prone position. This is basic to
infants of her age. The client is also already able to have a good grasp when an object is placed on
her palm. Those are the gross motor and fine motor skills that she can perform respectively.
VI. NUTRITIONAL STATUS
The client’s mother stated that she was purely breast fed since birth. The only exception was
when they tried to give her the concoction of boiled oregano leaves to help alleviate her cough and
colds. Her mother stated that the client was breastfed around 5 times per day, depending on the
