OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF MEDICINE
DEPARTMENT OF PEDIATRICS

PEDIATRIC HISTORY TAKING

and
PHYSICAL EXAMINATION

Submitted by:
Sioson, Catherine
Siscar, Aljun
Sison, Kristine Diane
Solis, Ilene Raisa
Solis, Joshua
Regina, Madie
Name of Patient: Aleyah Jane Dawatan
Informant: Willma Dawatan
Relationship with Patient: Mother
Reliability: 95%
Historian: Group 12
Date of Interview: October 12,2017

I. General data

Aleyah Jane Dawatan, 4-month old, female, Seventh Day Adventist, was born on
May 25,2017, currently residing at Sampaguita St. Karuhatan, Valenzuela City, consulted
for the first time at Fatima University Medical Center last October 12, 2017.

II. Chief complaint:

Colds

III. History of present Illness

The patient was apparently well until three weeks prior to consult, the patient was
reported to have colds. Nasal discharge was characterized as clear and watery in consistency.
The mother reported giving the patient Pheylephrine Hcl (Neozep) drops which provided no
relief.

Seven days prior to consult, still with the above symptoms but associated with non-
productive cough. No other associated symptoms like fever and weakness. The patient was
brought to a medical mission where she was prescribed with Amoxicillin 125mg/5ml, 0.5ml
every 8 hours for 7 days and Sodium Chloride Nasal Spray (Salinase) 2 sprays every 6 hours to
help relive the clogged nose. Slight relief was noted but due to the persistence of symptoms, the
patient sought consultation at Fatima University Medical Center.

IV. Review of Systems

General

(-) chills, (-) malaise, (-) fatigability, (-) weight gain, (-) pallor

Integumentary System

(-) pruritus, (-) pigmentation or texture change, (-) bruises

Head and Neck System

(-) headache, (-) tinnitus, (-) eye pain, (-) dizziness, (-) blurring, (-) photophobia, (-)
syncope, (-) vertigo, (-) diplopia, (-) ear pain, (-) discharge, (-) hearing loss, (-) epistaxis,
(-) toothache, (-) salivation
 Respiratory

(-) dyspnea, (-) chest pain, (+) cough

Cardiovascular

(-) palpitation, (-) shortness of breath, (-) orthopnea , (-) cyanosis

Gastro-Intestinal

(-) diarrhea, (-) nausea, (-) dysphagia, (-) vomiting, (-) constipation, (-) poor appetite, (-)
abdominal pain, (-) hematamesis, (-) flatulence, (-) hematochezia, (-) steatorrhea, (-)
abdominal enlargement, (-) melena

Genitourinary

(-) dysuria, (-) hematuria, (-) oliguria, (-) polyuria, (-) dribbling, (-) frequency, (-)
discharge, (-) incontinence

Musculoskeletal

(-) muscles pain, (-) swelling, (-) weakness, (-) joint pain & stiffness

Nervous/Behavioral

(-) syncope, (-) seizures, (-) tremors, (-) weakness or paralysis, (-) loss of memory, (-)
eating problems, (-) mood changes, (-) temper outbursts

V. Past Personal History

Gestational and Birth History

The mother only experienced morning sickness during her first trimester. No
bleeding, HPN, fever, infections and trauma. The mother had regular prenatal check-up.
She is non-alcoholic and non-smoker. She takes vitamins and ferrous sulfate.

The patient was born term at 40 weeks AOG thru normal spontaneous vaginal
delivery at Lipa General Hospital, in Batangas. The baby was not in distress. The patient
stayed at the hospital for 7 days after birth due to blood infection but was not able to
identify the disease, description that was given is blood infection characterized by
increased WBC and patient was treated while in confinement with antibiotics. When
patient was in third month approximately first week of September, patient experienced
colds but resolved in a week.

VI. Feeding History

The patient is exclusively breastfed but one week prior to consult the mother bottle-
fed the patient with bona because she presumed that she might transmit her virus to the
patient through breastfeeding.
 VII. Immunization History

The patient received BCG and Hepatitis B at birth. She completed the 3 doses of DPT
and Oral Polio vaccine. The immunization was given at the health center in Karuhatan.

VIII. Family Medical History

Patient’s father, John Romer is a welder maintenance worker, has no known disease and
is an occasional smoker and alcohol drinker. Her mother is Willma, 30 years old, is a
housewife who used to be a factory worker in food industry has no known disease also.
Patient is the youngest and the second child of the family. As for heredofamilial diseases,
there is no history of diabetes mellitus, asthma, hypertension, psychiatric illnesses, congenital
anomalies, chromosomal abnormalities, or any types of malignancies on both sides.

IX. Socioeconomic History

Patient is living with her parents, she has an older sister who is 4 years old and her
family is living in a studio type apartment with no rooms and only two windows. The
patient’s mother is a house wife while his father is a welder maintenance crew.

X. Environmental/Social History

Despite the father of the patient smoking, the mother claims that the father smokes
outside the house. There is also daily garbage collection in the area and their main source of
water is NAWASA.

Physical Examination

General survey

The patient was timid. She was silent during the consultation, but cooperative.
Ambulatory and conscious. She has a small body build with normal posture and gait. Good facial
expression, no gross deformities and no signs of cardio or respiratory distress.

Vital Signs:
Temperature: Axillary - 36.70C
Respiratory rate: 32cpm
Cardiac rate: 88bpm
Weight: 5kg

Anthropometric Data:

Height: 23 inches
Head Circumference: 41cm
Abdominal Circumference: 35.5cm
Chest Circumference: 38.2cm
Skin

The skin is brown in color, moist, thick and with good skin turgor, no hyperpigmentation
or hypopigmentation noted. The hair is black in color, well distributed. The nails are short and
clean, no clubbing or swelling noted. Skin was warm to touch.

HEENT

Hair is black, evenly distributed. No lesions seen. The cranium is normocephalic, no

gross deformities, symmetrical, no tenderness, no masses noted. Face is symmetrical no lesion,
no abnormal facial expression and no involuntary movements noted. Pupils are symmetrical,
round and reactive to light accommodation. Positive for direct and consensual light reflex.

Ears are symmetrical, no gross deformities. Lips and gums are pinkish, symmetric, no
lesion, no dryness and no swelling noted. Tongue is in the midline position. The neck is
symmetrical and no tenderness upon palpation.

Chest and Lungs

Upon inspection, skin is brown, warm to touch. There is no visible subcutaneous blood
vessels noted. There are no lesions found and muscles are well developed. Normal inspiration
and expiration. The bony thorax is elliptical, there are no bony deformities noted on the chest.
No nasal flaring, grunting and retraction. No supraclavicular, intercostal and subcostal in work of
breathing.

Upon auscultation, there is bronchovesicular sound on all lung fields. No abnormalities

like decreased breath sounds, crackles, wheeze, and stridor.

Cardiovascular

Adynamic precordium. PMI is located on the 4th interspace and midsternal line. S1 and
S2 are normal. No murmurs and abnormal heart sounds heard upon auscultation. No bruit noted.

Abdomen

There are no lesions, masses, skin discolorations, distention, fluid wave noted upon
inspection. Abdominal circumference is 52 cm. No bruit and high pitch sounds heard upon
auscultation. No palpable spleen or signs of hepatomegaly. Normal bowel sounds was also noted
with the patient.

Musculoskeletal

The patient has a good posture and no abnormalities in gait. All extremities are symmetrical.
No swelling of joints and is able to perform full range of motion.