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Said, Jaafar P. Third YearMSU-College of Medicine

DATE AND TIME OF HISTORY TAKING: February 24, 20 !IDENTIFYING DATA:

"le#chel $adi, % &o'. (ld, fe&ale, Fili)ino, *'la&, )re'en+ly re'iding in Tubod,*ligan Ci+y, ad&i++ed for +he r'+ +i&e a+ T M/.INFORMANT AND RELIABILITY: &o+her and aun+ie of +he )a+ien+, !1CHIEF COMPLAINT: being le+hargicHISTORY OF PRESENT ILLNESS:

Pre'en+ condi+ion '+ar+ed + el3e 25 day' )rior +o ad&i''ion a' an on'e+ of cough i+h yello i'h ')u+u& and runny no'e. She a' gi3en by her &o+her i+hCarbocy'+eine and na'al deconge'+an+ and ga3e 'o&e relief. Then 6 day' PT", +he')u+u& beca&e clear hi+e. "long +he dura+ion of illne'', +he )a+ien+ a' gi3en7hilo+8 + ice. Three %5 day' PT", +he )a+ien+ for&ed ra'he' o3er +he )o'+erior nec9and u))er bac9. Then + o 25 day' PT", +he )a+ien+ con'ul+ed in /eal+h Cen+er anda' )re'cribed i+h Cefale#in &l e3ery hour'5 and Parace+a&ol a' needed5and ga3e no 'igni can+ relief. (ne day PT", +he )a+ien+ '+ar+ed +o ha3e fe3er. Thir+y&inu+e' PT", +he )a+ien+ a' no+iced le+hargic and had di:cul+y of brea+hing hence)ro&)+ed +o ad&i''ion.PAST MEDICAL HISTORY:

The )a+ien+ had no )a'+ &edical )roble&' or )re3iou' ho')i+ali;a+ion. The)aren+' clai&ed +ha+ +he )a+ien+ had no )re3iou' infec+ion' or illne''e' e#ce)+ for+he dia)er ra'he' o3er +he bu++oc9' and gene+alia.BIRTH HISTORY:

The &o+her of +he )a+ien+ had done regular )rena+al chec9u) bu+ +he )a+ien+a' born a+ ho&e. The &o+her clai&ed +ha+ +he )a+ien+ i' born +er&, nor&ali+hou+ any co&)lica+ion'. The )a+ien+ a' fed i+h &il9 for&ula 'ince bir+h and'u))le&en+ed i+h 3i+a&in' Ti9i+i9i or Ceelin5.Developmental Mile tone :

The )a+ien+ '+ar+ed +o regard face a+ r'+ &on+h of age and 'i+ i+hou+'u))or+ a+ +hird &on+h of age. The )a+ien+ had no+ ye+ learned +o cree).Famil! Hi to"!:

The )a+ien+ had no fa&ily hi'+ory of hear+ di'ea'e or hy)er+en'ion, diabe+e'&elli+u', e)ile)'y, +hyroid di'ea'e' and cancer. $u+ on +he )a+ien+'< fa+her 'ide,+here i' 9no n +o ha3e a'+h&a.Imm#ni$ation an% Te t :

The )a+ien+ a' done i+h $C and + o do'e' of (P=.Pe" onal an% So&ial Hi to"!:

The )a+ien+ i' +he r'+ daugh+er of her non- or9ing fa+her, bu+ 'he i' +hefour+h child of her +eaching &o+her i+h ($ inde# of 4P4 40045.RE'IE( OF SYSTEMS:eneral> -5 For + lo'', - 5 fe3er, - 5 beha3ioral changeS9in> ?5 For i+ching, ?5 ra'he'/ead> - 5 For headache', - 5 in@uryAye'> ?5 ood 3i'ion, - 5 for eye )ainAar'> ?5 ood hearing, - 5 o+i+i' &ediaBo'e and Sinu'e'> - 5 For cold', - 5 'nee;ingMou+h and Throa+> - 5 For &ou+h 'ore', - 5 'ore +hroa+'e')ira+ory> ?5 For cough, ?5 dy')nea,Cardio3a'cular> - 5 For che'+ )ain, - 5 'ynco)e

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a'+roin+e'+inal> - 5 For 3o&i+ing, - 5 abdo&inal )ain, - 5 $MUrinary> - 5 For dy'uria, - 5 he&a+uria, - 5 )olyuriaeni+al> ?5 For i+ching, ?5 ra'he', - 5 di'charge'Peri)heral 3a'cular> - 5 For in+er&i++en+ claudica+ion and - 5 leg cra&)'Mu'culo-'9ele+al> - 5 For gai+ abnor&ali+ie', - 5 @oin+ )ain, - 5 &u'cle ea9ne''Beurologic> - 5 Sei;ure, - 5 )araly'i', and - 5 nu&bne''/e&a+ologic> - 5 For ane&ia, - 5 ea'y brui'ing, - 5 e)i'+a#i'Andocinologic> - 5 For hea+Dcold in+olerance, - 5 gro +h delay, - 5)oly)hagiaP'ychological> - 5 For hy)erac+i3i+y, - 5 de)re''ionP)! i&al E*amination:eneral "))earance> a a9e, irri+able, in re')ira+ory di'+re''=i+al Sign'>

Te&)> %!.4EC / > 4 b)& > % c)& +> !. GgS9in> )ale, ar& +o +ouch, good +urgor, dry, no di'colora+ion/AABT> nor&oce)halic, no &a''e', no ear di'charge', in+ac+ +y&)anic &e&brane,)in9i'h con@unc+i3ae, anic+eric 'clerae, no na'al di'charge', &oi'+ li)', no gu&bleeding or +hroa+ inHa&&a+ionBec9> There i' a )re'ence of ra'he' and clo++ed blood o3er +he )o'+erior nec9.Che'+ and ung'> Ii&ini'hed che'+ e#)an'ion, increa'ed +ac+ile fre&i+u', ?5'ubco'+al re+rac+ion, +here i' a )re'ence of con'+ric+ed air ay' 'ound coar'e5./ear+> +achycardic, regular rhy+h&, no &ur&ur'"bdo&en> 'of+, Ha+, no 'car', no le'ion', nor&oac+i3eac+i3e bo el 'ound',+y&)ani+ic, no organo&egaly, no +enderne'' on dee) and ligh+ )al)a+ion of alluadran+', -5 GPSA#+re&i+ie'> e ual )al)able )eri)heral )ul'e' , no defor&i+ie', no ede&a, C T le''+han 2 'econd'eni+al'> ?5 con+ac+ dia)er ra'he'

Imp"e ion: Comm#nit! A&+#i"e% Pne#monia , Hi-) Ri . $a'i' of *&)re''ion>

Symptoms > Fe3er, cough, di:cul+y of brea+hing and le+hargy are co&&on'y&)+o&' of )neu&onia.Risk factors: ecen+ U))er e')ira+ory *nfec+ion, o Socio-Acono&ic S+a+u'Physical Exam > in re')ira+ory di'+re'', Ii&ini'hed che'+ e#)an'ion, increa'ed+ac+ile fre&i+u', ?5 'ubco'+al re+rac+ion, ?5 con'+ric+ed air ay' 'oundcoar'e5.

Manage&en+>- "d&i+ +he )a+ien+- Secure con'en+ +o care- =DS 4 hour'- BP(- Bebuli;e i+h Salbu+a&ol ? *)ra+ro)iu& !&l + ice e3ery 20 &in.- ab'> C$C i+h diKeren+ial, Che'+ Lray-Med'> . Parace+a&ol 2!0D!, !&l e3ery 4 hour' )rn for fe3er

2. ";i+hro&ycin 0&g P( e3ery hour' for 4 day'.- efer accordingly- Than9 You.

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P ( ASS B(TAS

S (n '+ /I, )a+ien+ i' a a9e and no+ in re')ira+ory di'+re'' bu+ '+ill ha' cough.

( en. Sur3ey> con'ciou', afebrile, no+ in di'+re''=i+al Sign'> / > 0Nb)&, > %Oc)&, Te&)> %N.!S9in> ar& +o +ouch, good +urgor/AABT> anic+eric 'clerae, )in9i'h con@unc+i3a, no na'al Haring, no +on'illar

e#uda+e'Bec9> 'u))le, no ly&)hadeno)a+hyChe'+ and ung'> ?5 coar'e, no re+rac+ion/ear+> nor&al ra+e regular rhy+h&, no &ur&ur'"bdo&en> 'of+, Ha+, no organo&egalyA#+re&i+ie'> no ede&a, no 'car', no defor&i+ie', e ual )eri)heral )ul'e'

" PC"P, i&)ro3ing

P $rea'+fed +he baby.*=F +o follo I!BM +o run a+ ! g++'D&inab'> Follo u) for Che'+ Lray, C$C i+h diKeren+ial and cul+ure,Med'> . Parace+a&ol 2!0D!, !&l e3ery 4 hour' )rn for fe3er

2. ";i+hro&ycin 0&g P( e3ery hour' for 4 day'.Moni+or *n+a9e and (u+)u+ e3ery hour'Moni+or =i+al Sign' e3ery 4 hour'efer for any unu'ual nding' and once ab re'ul+' are in

Than9 You

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NEONATAL HISTORY Gene"al Data: " 2. 9g, % - ee9 " ", fe&ale, ne born deli3ered 3ia nor&al')on+aneou' deli3ery, ce)halic )re'en+a+ion i+h ")gar Score of ,6 +o a 6 yr oldo&an, P &o+her.

(b'+e+rician> Ir. ede'&a Pedia+rician> Ir. egado'Ia+e and Ti&e of Ieli3ery> February 4, 20 !Q %> O PM

Mate"nal OB Hi to"!: Pa+ien+ a' born a+ % ee9' ge'+a+ion by MP5 +o a 6-year old o&an ho a' P 00 5 a+ +he +i&e of deli3ery. a'+ Men'+rual Perioda' June 2N, 20 4 and A#)ec+ed Ia+e of Ieli3ery a' March %, 20 !.

Mo+her '+ar+ed a++ending +o )rena+al chec9-u) on "ugu'+ 20 4 a+ a /eal+hCen+er and a' recei3ing )rena+al care fro& a &id ife. She had a +o+al of &ore+han +en 3i'i+'. (n her N +h ee9 of )regnancy, 'he ac uired cough bu+ no&edica+ion' +a9en. Bo in+a9e of alcohol and u'e of cigare++e '&o9e. $lood Ty)e i'un9no n. Ul+ra'ound a' no+ done. Bo bleeding or ')o++ing no+ed. There i' a fa&ilyhi'+ory of hy)er+en'ion bu+ no fa&ilial +endencie' +o Iiabe+e' Melli+u', "'+h&a,Mul+i)le Pregnancie' and Malignancy.La/o" Hi to"!: U+erine con+rac+ion' co&&enced a day )rior +o con'ul+ hich erecharac+eri;ed a' &ild la'+ing abou+ %0 'econd' and occurring irregularly fro& ! +o%0 &inu+e'. *+ e3en '+o))ed a+ +i&e'. "c+i3e '+age of labor '+ar+ed 4 hour' )riori+h a &ore in+en'e con+rac+ion' occurring e3ery 2 +o % &inu+e' for N0 'econd'.Me&brane ru)+ured ')on+aneou'ly hour )rior +o deli3ery.Delive"! Hi to"!: "li3e, +er&, fe&ale deli3ered 3aginally, ce)halic i+h ")gar'core of a+ '+ &inu+e and 6 on +he ! +h &inu+e. Bo re'u'ci+a+ion' re uired.e')ira+ory eKor+ a+ bir+h a' ')on+aneou' a' e3idenced by good cry. /ear+ ra+egood +hroughou+.

P)! i&al E*aminationeneral Condi+ion> &a+ure ne born i+h good cry, good +one, good ac+i3i+y=i+al Sign'> eng+h> ! c& /C> %4 c& CC> %% c& "C> % c& M"C> c&

$ir+h eigh+> 2. 9g Te&)> %O / > 2% b)& > 4 c)&S9in> no ic+eru', no ra'he', no bir+h &ar9/AABT> )a+en+ an+erior and )o'+erior fon+anel', )re'en+ ca)u+ 'uccedaneu&, noce)halhe&a+o&a, eye' are nor&al in 'ha)e and 'i;e i+h e ual red reHe#e', noca+arac+, no eye di'charge', ear' are nor&ally 'e+ i+h no ano&alie', nare' a))ear)a+en+, no clef+ li)D)ala+eBec9> no nec9 ebbing, no &a''e'Che'+ and ung'> no re+rac+ion', e ual &o+ion bila+erally/ear+> nor&al ra+e regular rhy+h&, no re+rac+ion', '+rong and e ual )ul'e' on alle#+re&i+ie'"bdo&en> 'of+, no &a''e', no organo&egaly, u&bilical cord i+h 2 ar+erie' and 3eineni+alia> gro''ly fe&ale"nu'> )a+en+$ac9> no defor&i+ie', '+raigh+ ')ineA#+re&i+ie'> no defor&i+ie', no frac+ure, 'y&&e+ric, &o3e' all four li&b', co&)le+e'e+ of nger' and +oe'

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