DOCUMENTATION

Our group conducted an interview to Salcedo Family for their five-year-old daughter named
Jennifer Salcedo to accurately recognize clinical signs, choose appropriate treatments, and
provide counselling and preventive care. We do our initial visit in November 10, 2021. Before
the interview starts, We make sure that we had already established rapport to both mother and
her child and to other family members inside their house so that she can easily provide all of the
important questions that we needed to asked for data completion and also to make them more
comfortable throughout the whole interview.

Furthermore, we made clear and had an agreement with them that all of the following data that
we’ve gathered for this information will stay confidential between our clinical instructor of the
course to ensure their safety especially the child and use it only for medical purposes .

Our client is Jennifer Salcedo a 5-year-old child with a height of 127 cm, weight of 17.85 kg and
a temperature of 38 °C.

Based on our documentation she experience cough or difficulty in breathing in 4 days straight
and counted 84 beats per minute. No symptoms of diarrhoea and she did not experiencing
some danger sign

There are no signs of sunken eyes, restless and irritable, and drinking early or thirsty and when
we pinched the abdomen skin it goes back so it’s normal. We classify Jennifer as No
Dehydration .

Patient experiencing fever with 38 °C.in 4 days she experiencing simple cough or cold or other
viral infection. We advise mother If the fever has been present every day for more than 7 days,
refer to Give Jennifer Paracetamol to prevent fever for assessment theirs

There are no signs of stiff neck, bulging fontanelle, or positive malaria test. We classify Jennifer
as No measles .

No ear problem but child is awake at night.

Experiencing sore throat and have symptoms of runny nose cough and cold. No oedema on
both feet and healthy red-pink colour, so there is no pallor for anaemia. Jennifer and mother
have no HIV infection.

Jennifer has no close TB contact, cough for 3 weeks, loss of weight, Mid upper arm
circumference of 12.5 cm and more in score of ≥ 2 or more theirs fever for 7 days, and not
growing well being fed by her mother with 5 large servings on meal.

At Birth Jennifer have BCG vaccine at OPV 0. On her 6th week she got vaccinated with Dapt-
ipv-hb-hib 1, OPV 1, RV 1, PCV 1 and vitamin A. On her 10th week she got vaccinated with
Dapt-ipv-hb-hib 2. On 14 weeks she got Dapt-ipv-hb-hib3, RB2, and PCV 2. On her 6 moths
she got measles and Mebendazole. On her 9 months she doesn’t have PCV 3 and on her 12
months she doesn’t have measles 2. On her 18 months she have Dapt-ipv-hb-hib4 and on her
6yrs she don’t have td

Slides

1. Imci form

2. Colds? (title)

3. Objectives (pagawa mo to sa kabila)

4. Info baby

Name:

Age:

Place of Birth:

5. Underlying issues (bakit nagka colds)

6. Vital signs

BP

, PR,

RR-84 BPM

TEMP-38 DEG CELSIUS

7. Assess Classification Treatment

Based niyo to sa row na tinuro ni Ma'am if green ba siya or yellow pero sa tingin ko yellow kayo
kasi may fever cough and colds
8. Immunization status

-Complete na ba si baby na vaccine or bakuna

-May natake pa ba aside from essential vaccines (rabies or flu vaccine)

-Dental Check up

-Deworming

-Vit A

9. Feeding

Height: 127cm

Weight: 17.85 kg

MUAC SCORE- exact dapat to na bilang ng left upper arm

May interpretation pa to pero wala kayo nakalagay 12.5 or more ano yun

FEEDING: 3 TIMES A DAY

ANEMIA

-no edema ba on both feet

-no palmar pallor din ba

9. COUNSELLING

-state ano sinabi niyo kay mother throughout the interview