CLINICAL FACE SHEET

Case Number:__98375_______________
Name: Reyes, Pearl Celeste Herano Age: Date of Birth: Place of Birth: Category
12 08/20/2009 Quezon City, of Patient:
year Manila Pedia
s old

Home Address: Magat Salamat, Project 4, Quezon Sex: F Civil Religion: Nationality:
City Status: S Catholic Filipino

Next of Kin: Lucy Reyes Relationship Address: Contact No.:09789177780

: Mother Magat Salamat, Project
4, Quezon City

Date Admitted: Time: Date of Discharge: Time: No. of Hospital

11/17/2021 ___8:35_____ ________ Days:
A.M. A.M.
________ ________
P.M. P.M.

Ward: Pedia Attending Physician: Dr. Real Admitting Nurse: Daryl Joshua
Saturno

ADMITTING DIAGNOSIS:
seizure; productive cough; stiffness of extremities; fever for 3 days

FINAL DIAGNOSIS: Community Acquired Pneumonia – Moderate Risk; T/C Bacterial Meningitis ICD 10 Code:

Condition on Discharge: Disposition:

[✓ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD [ ] home
[ ] unimproved [ ] not autopsied against for follow up advice

COMPLICATIONS: None

OPERATION/PROCEDURE DONE: None

Review for completeness:

 Signature over Printed Name
of Attending Physician
(Sig.)
_______Real, G._____
______ Signature over Printed Name
(Record Officer)
___________________________________________

PATIENT’S DATA

1. Name of Patient: Reyes Pearl Celeste Herano 2. PIN

Last Name First Name Middle Name 3. Age 12 years old

5. Chief Complaint Seizure; Productive cough; stiffness of extremities; fever for 3 days

4. Sex
Male Female ✓

6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

Community Acquired
Pneumonia-Moderate Risk: T/C Bacterial 8. b. 2nd Case Rate Code
Meningitis

9. a. Date Admitted: 9. b. Time Admitted:

l1l1l ¯ l1_l7_l ¯ l2_l0l2_l1l l__0_l_8__l ¯ l__3_l_5__l AM PM month day year hour min

10. a. Date Discharged: 10. b. Time Discharged:

l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM month day year hour min

REASON FOR ADMISSION

1. History of Present Illness:

Lethargic, has dry skin, sunken eyes, and skin was flushed and warm to touch upon assessment; Rales and crackles were also present upon auscultation,

2. a. Pertinent Past Medical History: Seizure

2. b. OB/GYN History:
G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA

3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

• Altered Mental Sensorium • Diarrhea • Hematemesis • Palpitations

• Abdominal cramp/pain • Dizziness ✓ • Hematuria • Seizures ✓
• Anorexia • Dysphagia • Hemoptysis • Skin rashes
• Bleeding gums • Dyspnea • Irritability • Stool, bloody/black
• Body weakness • Dysuria • Jaundice tarry/mucoid
• Blurring of vision • Epistaxis • Lower extremity edema • Sweating
• Chest pain/discomfort • Fever • Myalgia • Urgency
• Constipation • Frequent urination • Orthopnea • Vomiting
• Cough ✓ • Headache • Pain, ____________ (site) • Weight loss
• Others:
_________________________

4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason _____________________________________________________ Name of
Originating HCI ____________________________________________
5. Physical Examination on Admission (Pertinent Findings per System)
General Survey: • Awake and alert • Altered sensorium,_____Drowsy__________________

Vital Signs: BP:__103 bpm_____________ HR:_____90 bpm__________ RR:___33 cpm____________ Temp.;__38.5 C_____________ Wt.:_______________(pedia
patients)

HEENT: • Essentially normal • Abnormal pupillary reaction • Cervical lymphadenopathy • Dry mucous membrane • Icteric sclerae • Pale
Conjunctiva • Sunken eyeballs • Sunken fontanelle
Others:_____________________________________