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Was born at June 6, 2004 also at Batangas. He is a Filipino and a Roman Catholic. This information came from his mother and was taken last August 19, 2009. Chief Complaint “Hindi siya masyadong makahinga dahil sa sipon niya.”, As verbalized by the client’s mother. History of Present Illness Two days ago, the client had a cold and sometimes breathing in his mouth. And the next day, they went to the health center to consult a barangay health worker (BHW) and were prescribed with the appropriate medication for the said illness. Now the child still has a cold. Past Medical History Prenatal History The mother had a planned pregnancy. She was 35 years old when she got pregnant with the client. During her pregnancy, she did not have any problems. She did not take any medications while she was pregnant and had a check-up all through out her pregnancy. Natal History The client was delivered through NSD with cephalic presentation on June 6, 2004 with no complications. Post-natal History There were no post-delivery complications. The client was breastfed until he was 1 year old. The mother stated that the client had complete vaccination. Nutrition The client was breastfed for a year, and then was transferred to bottlefeeding then to soft foods. He has no food allergies but during his illness he is restricted to eat cold foods.
Developmental Milestone The client can state his whole name and can also dress himself without supervision. Health Maintenance The client’s mother stated that her son has complete vaccination. He had BCG, DPT, OPV, Hepatitis B, and Measles vaccine. Acute Infection Besides his cold, the client had no other complications or infections. Family Health History The client’s grandfather has asthma and his grandmother has diabetes on his father side, and his grandfather has hypertension and his grandmother was healthy oh his mother side. His father and mother did not inherits their parents diseases. Genogram: Father Side Mother Side
Legend: - Boy A – Asthma - Girl H – Healthy HPN – Hypertension DM – Diabetes Mellitus
Social History The client and his family live in a concrete, well-ventilated, and well-lighted home. His father works a driver and as their only source of income because his mother is just a housewife.
Physical Assessment General Appearance My client has a small frame body built, upright in posture with smooth rhythmic gait. He is appropriately dressed and he has no bad odor. And with a vital signs of: Temperature – 36.6’C; RR – 30cpm; PR – 85bpm. Mental Status My client is conscious to time, place, and person oriented. He is using simple words as way of communication and language and he is very cooperative. He was able to separate from his mother easily. Skin My client has normal skin color with a warm body temperature. He has dry moisture, smooth in texture, and with evenly hair distribution. He has a skin turgor of elastic and mobile and doesn’t have any lesions. Nails He has an convex 160-nail plate shape and his nail condition is smooth and he has pink nail bed color. His capillary refill is within 3 seconds. Head and Face My client has a proportionate skull to his body size and he has fine and evenly distributed hair with a tender scalp and his face is symmetrical and his facial movement is symmetrical and easy movement.
Eyes My clients eye condition is straight normal and he has thin eyebrows in hair distribution and his eyelids have effective closure and his blink response is bilateral frequent and his eyeballs are symmetric. His conjuctiva has clear bulbar and pink palpebral and his sclera is white and his pupils are equal in size and he has brisk reaction to light and accommodation both right and left eye. His visual acuity is able to recognize objects within 2 feet away. His lacrimal apparatus is moist. Ears My clients auricle is symmetrical and the color is normal racial tone and his texture and elasticity is tender and elastic. His pinna recoils when folded and his external canal have some cerumen on it. His hearing acuity responds to normal voice and he also respond to whispered voice within 2ft. away. Nose My clients nose color is normal racial tone and his septum is on the midline and his mucosa is pink and the patency is both patent. His nasal cavity is moist and his sinuses are non-tender. Mouth My clients lips is symmetrical and pink in color. His mucosa is pink and his tongue is on the midline and it is rough in texture and the color is pink. His tongues movement is movable. His teeth are not complete and his gums are in pink in color and no mouth sores. Pharynx My clients uvula is on the midline and his mucosa is pink in color. His tonsils are not inflamed and his posterior pharynx is congested and his gag reflex is present. Neck My clients neck muscle is equal in size and his lymph nodes are not palpable and his trachea is on the midline and his thyroid gland is not palpable. Chest and Lungs My clients chest shape is AP to lateral ratio of 1:2 and her lung expansion in the anterior side is symmetrical and on the posterior side is symmetrical. His fremitus
is symmetrical and her breathing pattern is regular and bronchovesicular in sound. Upon percussion the sound is resonant and her costal angle is on 45 degrees. Heart My client has a peripheral pulses at both sides of the body have equal strength. And his heart sounds were heard over the apical, aortic, tricuspid and pulmonic area. Breast and Axilla My client refused to have breast examination so we don’t have the chance to assess his breast and axilla. Abdomen My clients skin integrity is normal racial tone and unblemished. His contour and symmetry is flat and his movement is symmetrical and his bowel sounds are normoactive. His abdomens palpation is tender and his liver is palpable. Genitalia My client refused to have the examination so we don’t have the chance to assess his genitalia Rectum and Anus My client refused to have the examination so we don’t have the chance to assess the part of his rectum and anus. Upper and Lower Extremities My client has a motor strength of 4/5 and he has normal hair distribution, was able to partially oppose force and no lesions.
Anatomy and Physiology
Nasal Cavity The cavity on either side of the nasal septum, extending from the nose to the pharynx, and lying between the floor of the cranium and the roof of the mouth. Pharynx The upper section of the alimentary canal that extends from the mouth and nasal cavities to the larynx. Larynx The part of the respiratory tract between the pharynx and the trachea, having walls of cartilage and muscle and containing the vocal cords enveloped in folds of mucous membrane. Trachea The airway that extends from the larynx into the thorax where it divides into the right and left bronchi. It is composed of thin incomplete rings of hyaline cartilage connected by a membrane called the annular ligament. Also called windpipe. Bronchus Either of two main branches of the trachea, leading directly to the lungs.
Epiglottis The thin elastic cartilaginous structure located at the root of the tongue that folds over the glottis to prevent food and liquid from entering the trachea during the act of swallowing. Lungs Either of the two saclike organs of respiration that occupy the pulmonary cavity of the thorax and in which aeration of the blood takes place. It is common for the right lung, which is divided into three lobes, to be slightly larger than the left, which has two lobes. Pleural cavity The potential space between the parietal and visceral layers of the pleura. Also called pleural space. Diaphragm A musculomembranous partition separating the abdominal and thoracic cavities and functioning in respiration.
Pathophysiology Exposure to Indoor and Outdoor Allergens
Swelling of Membranes that Line the Airways
Reducing the Airway Diameter
Contraction of the Bronchial Smooth Muscle that Encircles the Airways (Bronchospasm)
Futher Narrowing and Increase Mucus Production
Diminishes Airway Size and Entirely Plug Bronchi
Cough and Cold
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