D.

Maternal and Prenatal History

Maternal – Kidney disease, asthma

Paternal – hypertension, asthma

E. Developmental History

Theorist Age Sex Patient Description

Erik Erikson’s Birth to 12- 18 For both male and I observed that she depends
Psychosocial Theory months female primarily to her mother to feed
(Trust vs. Mistrust her. Yet there were times she
stage) would respond when her
grandmother and dad gives her
food. I have seen that she is
most calm when breastfeeding. I
sometimes tried to make funny
faces and she smiled once in a
while.

Jean Piaget’s I noticed that she always

Cognitive Birth to age 2 For both male and watched her favorite cartoon
Development female movie and know what button to
(Sensorimotor Stage) press so she can hear the sound.
She could immediately
recognize a syringe and cries.
She always tried to reach out
the thermometer everytime I
finished taking her temperature.

Lawrence Kohlberg’s I observed that the mother could

Moral Development For children For both male and not immediately make her
(Pre- Conventional female daughter stop crying even if she
Level) would mention scary things that
might shop up if she did not
stop.
F. Nutritional History

G. Immunization

According to her mother, she said that her daughter only had BCG vaccine.

H. Physical Examination (Cephalo-caudal)

Body Parts Technique Used Findings

(area assessed)
Skin
 Color Inspection Fair-skinned, no
discoloration and
 Texture Palpation hyperpigmentations smooth,
 Temperature Palpation soft warm to touch moist due
 Moisture Palpation to perspiration

Nails
 Color of nailbed Inspection Pink and clean
 Texture Palpation smooth
 Shape Inspection convex curvature
 Nail base Inspection firm

Hair
 Color Inspection Black
 Distribution Inspection Evenly distributed
 Moisture Inspection Not excessively dry or oily
 texture Inspection Fine, silky, resilient

Eyes
 eyebrows Inspection Symmetrically aligned, equal
movement
 eyelashes Inspection Slightly curved upward
 eyelids Inspection Smooth, pink, close
symmetrically
 ability to blink Inspection Blinks voluntarily and
bilaterally

 ocular movement Inspection Eyes move freely

 size Inspection Medium
 texture Palpation Mobile, firm, not tender
 conjunctiva Inspection transparent with light color,
 shiny and smooth, no lesions

 cornea Inspection Clear, shiny , smooth,

transparent

 pupils Inspection Equal size, round and

constricts briskly, equally
reactive light
Nose
 symmetry, shape, size Inspection symmetrical ,
and color smooth and fair
 mucosa color Inspection pinkish
 nasal septum Inspection oval and symmetrical nares
 nasal discharge Inspection with clear discharges
 sinuses Palpation not tender
Mouth
 lips Inspection Pinkish, symmetrical, smooth
and moist
 gums Inspection Pinkish and moist
 buccal mucosa Inspection Pinkish, soft, moist
 tongue Inspection Pinkish, small, symmetrical
 uvula Inspection at the midline
 teeth Inspection 6 milk teeth

Heart
 Heart rate Auscultation 140 bpm
 Heart sound Auscultation clear

Thorax and Lungs

 Symmetry Inspection Symmetrical
 Respiratory rate Inspection 26 bpm
 Breathing pattern Inspection Irregular, with effort
 Lung/breath sounds Auscultation Ronchi
Abdomen
 Contour Inspection Flat
 Texture Palpation Smooth
 Frequency and Auscultation Soft gurgling sound
character
Upper Extremities
 Skin color Inspection Fair
 Size Inspection Equal and appropriate for her
body
 Symmetry Inspection symmetrical
Lower Extremities
 Skin color Inspection Fair
 Size Inspection Equal and appropriate for her
body
 Symmetry Inspection symmetrical
Neurologic
 Level of consciousness Interview Responds quickly when name
was being called
 Behavior and Interview Makes eye contact, normal
appearance behavior for a toddler
 Mood Interview Irritable
 Mannerism and actions Interview Likes to cuddle to her mother