PEDIATRIC CLINICAL CORRELATION

FRACTURED HISTORY OF A CHILD

Student’s guide
PCC August 18, 2020

Date of Admission: August 12, 2015

General Data: Walter Santos, 4 year old male, Catholic, presently

residing in Quezon City was admitted for the first
time at the UST Hospital.

Informant: Mrs. Elenita Santos (mother), Reliability: 100%

Chief complaint: pneumonia

History of Present Illness:

August 8, 2015: the patient was noted to have cough and colds.

August 9, 2015: The cough and colds progressed. This time, it was accompanied by fever that
was not very high. After a few hours, the fever became high grade, and the patient started to
cough out sputum, amounting to about 5 tsp. The patient was brought to a physician who gave
him Tempra, 1 tsp every 4 hours and Solmux, 1 tsp 3x a day.

August 10, 2015: the cough, colds and fever continued for the next two days.

August 12, 2015: The mother noted that the patient had difficulty of breathing. He was also
noted to be cyanotic. He was then brought to UST Hospital and was admitted.

Review of Systems:

General Survey: fairly nourished,

Skin: no rashes
HEENT: flaring of the alae nasi,
Respiratory: frequent coughs and colds
Gastrointestinal: no vomiting nor loose bowel movements
Genitourinary: no edema

Musculoskeletal: no limitation of motion

Gestational History: born to a 34-year old mother by NSD in Lourdes Hospital.
Feeding History: eats table foods served with family
Growth and Development: at par with age
Immunization History: complete
Past Illnesses: no previous hospitalizations
Family History: Father, apparently healthy, non-smoker, non-alcoholic beverage
drinker
Mother: apparently healthy; smoker

Socioeconomic and Environmental: The family lives in a rented room with poor
ventilation. The father and the mother both work and the child is
taken cared of mostly by the grandmother.