E.

PATIENT’S PROFILE
i. BIOGRAPHIC DATA

Name : Nathaniel Drew John Jacob Fritzanhatager

Age : 11 months and 7 days old
Gender : Male
Birthdate : November 14, 2020
Birthplace : Not indicated
Civil Status : Single
Nationality : Filipino

ii. CLINICAL DATA

Chief Complaint : vomiting and loose bowel movement of 5x/day with color of greenish brown
stool for the past week.
Date of Admission : October 21, 2021
Time of Admission : 8:00 AM
Hospital : Davao Doctors Hospital
Room and Bed No : 203-A
Attending Physician : Dr. Gin Min Who
Tentative Diagnosis : Acute gastroenteritis with mild dehydration.

iii. PAST HEALTH HISTORY

Patient NDJJ, weighed 2.5kgs at birth, healthy baby. Patient has no known foods, drugs, or
environmental allergies. The patient has no chronic conditions, and past hospitalizations.

When conducting a thorough health assessment on the patient and interviewing his mother
Nathalie for the patient’s developmental progress, everything was healthy and normal.

As for the gross motor: NDJJ is normal and healthy at 1 month, the patient is able to lift his head
a few moments at a time, has a strong grasp and would often hold mother’s finger. At 2
months, NDJJ is able to raise his head and maintain that position but still cannot raise chest, he
can hold his head fairly when sitting, steady and now opens his hands, In his 3rd month, NDJJ
can now lift his head and shoulders well off the table and look around when prone. Able to grab
objects. At 4 months, NDJJ can now lift his chest off the bed and look around, turning head
from side to side, no more head lag, can now bring his thumb and fingers together. In his 5 th
month, NDJJ can completely turn over. He can now straighten his back when held in a sitting
position. He can now accept objects by grasping them with his whole hand. He can also reach
and pick up objects without the object being offered. At 6 months, NDJJ is now able to raise his
chest and upper part of his abdomen off the bed. He can sit momentarily without support but
goes back to lying down in a short while, can now hold objects in both hands and will usually
drop one toy when a second one is offered at the same hand. On his 7 th month, NDJJ can sit
alone with hands held forward for balance and can now transfer toys from one hand to the
other. In his 8th month, he can sit properly without any additional support. In his 9 th month, he
is now able to crawl.

As for the fine motor: in his 3rd month, He is able to hold his favorite small rattle without easily
letting go of it. At 6 months he could hold a spoon and tried to feed himself. On his 10 th month,
NDJJ is able to grasp things using his fingers and pick up small objects.

As for speech & language, at 4th month, NDJJ is talkative and responds by cooing and babbling
. NDJJ can speak “goo-goo” at his 5th month, On his 9th month, NDJJ was able to speak his first
word “da-da”, and can speak “no” at 11th month.

As for the patient’s cognitive ability, at 2nd and 3rd month,NDJJ likes it when his music box is
played and usually doesn’t fuss.

As for the social/emotional development, when mother changes his diapers, NDJJ would look at
her face and smile at her. On his 3rd month, he smiles when he sees his mother approaching to
feed him. NDJJ is comfortable with her mother, and sometimes would prefer her mother over
his dad. He would sometimes cry when his father was the one to change the diapers. At 7
months, NDJJ shows obvious fear of strangers and during his 8th month,He cries when other
people try to carry him or talk to him in his 10th month,He likes the game peek-a-boo. And
listens when called by his name.

NDJJ’s teeth start to appear at 6months.

iv. PRESENT HEALTH HISTORY

In the past week NDJJ has been feeling sick, he hasn’t been drinking his milk as much and he is
always vomiting, three times a day and has loose bowel movement. The mother reported that
she had to change his diapers 5 times a day with a watery stool. She also noticed that the color
of the poop is greenish brown. Baby NDJJ is starting to feel weak and doesn’t interact much and
cries and is irritable most of the time as the mother stated.

During physical examination, NDJJ is a bit weak and irritable. He is always crying and doesn’t
drink much milk. He is warm to touch with a body temperature of 38.5 °C with occasional
complaints of abdominal pain. His eyes appear a bit sunken. He weighs 9 kgs and likes to sleep
a lot. When checking his vital signs, his results where HR – 100bpm, RR 34cpm, BP of
100/60mmHg. His head appears to be asymmetric. His eyes are normal, pupils equally round
and reactive to light. His ears a symmetrical with clear tympanic membranes and clear bilateral
canals. His nose is located at the midline of the face with no nasal septal deviation. A little bit of
nasal flaring is noted. Pharyngeal mucosa is pink and moist. His mouth is a bit dry and cracked.
With central and lateral incisors appearing on the top and bottom of his mouth. His
oropharyngeal are pink and moist, no erythema noted, no tonsillar enlargement noted. Neck is
located at the midline of the body and no tracheal deviation noted. His heart rate is around
100bpm with regular rhythm. Heart sounds audible with clear S1 and S2 sounds. No murmur,
rubs and gallops noted. Chest appears to be normal with respiratory rate of 34bpm. He appears
to be breathing a bit faster than normal, nasal flaring is noted and use of accessory muscles is
apparent. His O2 sat is 94% with slightly cyanotic skin color. His abdomen is a little bulging, soft
and nontender with 40 bowel sounds heard per minute. He is able to move his arms and legs
and is able to stand with support. He is conscious and irritable but a bit sleepy.

v. FAMILY HISTORY

There is no reported history of Baby NDJJ’s family.

Genogram;

Mother Father

Nathalie Drew John Jacob

Baby NDJJ

LEGEND:

MOTHER / Nathalie Drew

FATHER John
Jacob

BABY / Nathaniel Drew