8/12/2019 Patient 01 06252014

1/3

MARTIN FEDERIC M. PALCO

Medicine II PEDIATRICS

I. General Data

Patient GKYE, 3 years old, born on March 14, 2011, Male, Child, from Villa, Iloilo

City. Newly admitted at June 24, 2014 for shortness of breath and paleness of nail

beds and lips. Informant is the mother of the child, Mrs MCY with 95% credibility

II. History of Present Illness

2 days prior to admission, upon awakening in the morning, the informant noticed

the patient having nasal cathar with yellowish secretion. Broncophen 1 teaspoon

administered orally as claimed with no relief. Still with nasal cathar, on the evening,

patient started to have non-productive cough with no associated difficulty of

breathing as claimed. Ambroxol 1 teaspoon administered orally. With no medical

consultation made, informant administered Cefalexin 1 teaspoon orally as claimed.

A day prior to admission, nasal cathar was gradually resolving as claimed.Patient was continued to be given Cefalexin 1 teaspoon and Ambroxol 1 teaspoon

orally by the informant. Still with non productive cough, informant noticed the patient

having difficulty of breathing as manifested by nasal flaring and shortness of breath.

Still with no medical consultation made, Hivent nebulization was administered with

slight relief as claimed. On the evening, patient reported abdominal pain associated

with cough and difficulty of breathing as claimed.

On the day of admission, upon awakening in the morning, informant noticed the

patient to feel warm. Temperature taken per axilla and was noted to be 37.7 degreesCelsius as claimed. Calpol 2 teaspoon administered orally. Fever was resolved as

claimed. Still with cough and difficulty of breathing, informant noted paleness of the

nailbeds and lips. Thus, the admission.

8/12/2019 Patient 01 06252014

2/3

8/12/2019 Patient 01 06252014

3/3

VI. SOCIOECONOMIC/ ENVIRONMENTAL

The family with the patient lives in a generally healthy environment as claimed. Being

unmarried, the father provides financial support for the patient, with the informant as the

main caregiver of the patient. Father, 32 years of age, works as an agent in a BusinessProcess Outsourcing company. The patient together with his sibling lives with the

informant

VII. PHYSICAL EXAMINATION

Vital signs noted as follows: temperature of 36,7 degrees Celsius taken per axilla,

cardiac rate of 119 beats per munite, synchronous with the pulse, regular in rate and

rhythm. Respiratory rate at 30 breaths per minutes, with no use of accessory muscles inbreathing and no nasal flaring. Blood pressure of 80/60 mmHg. Height is 98 cm and

weight of 14.7 kilograms.