ADDITIONAL QUESTIONS

Biographical data:
*check my message nalang noon hehe
Pang ilang anak siya? Pangatlo
Blood type? O
Ilang gestational weeks pinanganak? 37 weeks
Date of first assessment? October 8, 2021 4:30 pm
Date of second assessment? January 7, 2022 9:30 pm
Initials of guardian and relationship? Mother – J.M

Chief Complaint
**Note: Please be specific sa dates and other details. Mas maganda if may ‘phrase’ mismo na galing kay
mother

May voice record na iupload sa gdrive

History of Present Concern

**Note: Yung orig cc ng paper, lipat natin lahat dito part.
***If you can mention the dates, months, events in a chronological order, mas maganda. Let the mother share
the story from beginning to latest events.

1. How many days does the fever of the baby occurring before rushing to the hospital? Specify date.
January 3 ng gabi hanggang January 4 may fever, January 5 ang monthly check up dahil on monitoring
si patient L.M
2. Did the baby need intensive care? Ano yung interventions na ginawa sa kaniya? Oxygen, IV, tests, etc
No
3. COLDSPA QUESTIONS
a. Describe the signs and symptoms, how is the baby feeling about it?
Fever, cough and colds. – umiiyak at iritable
b. When did it begin?
January 3 ng gabi hanggang January 4 may fever, January 5 ang monthly check up
c. Can you identify a specific location of the pain the baby is feeling?
d. How long does it occur and does it reoccur? Twice
e. How bad the pain is? Can you possibly rate it from 1-10 (10 is the highest) Or pwedeng idescribe
kung gaano kalala iyak ni baby becasue of it. 8/10
f. What are you actions to make it better? And even to make it worse?
Sinasayaw, kinakantahan, nilalaro o hinehele
g. What other symptoms occur with it?
None
Past Health History

Birth History
 When and where was the child born? July 13, 2021 @ De Leon
 Was labor induced? Yes or no? No
 Was labor help with medication? Yes or no? N/A
 Duration of labor? N/A
 Was the baby born at term? Yes, No, Early or Late? 37 gestational weeks
 What was the method of delivery? ____________
 Choose below on the type of delivery:
- Head first
- Feet first
- Breech
- Cesarean
 Were there any concerns during delivery or interventions required?
None
 Child’s birth weight 31.5 kg & 51cm
 Apgar Score (if known)
 Did the child had illnesses during the hospital stay? Yes or no? If yes, Specify_____
 Did child remain longer in hospital than mother? 3 days
 ADDITIONAL QUESTIONS
 How was/is the baby fed? Bottle or Breast? 2 months bottle, 4 months breast
 Measurements: upon birth ha hindi ngayon
-head circumference
-chest circumference
-Abdominal circumference
-Length (crown of head to heel)

1. All immunizations na natapos na niya (Immunization status)

Check gdrive may pictures yung mga natake niyang vaccines
2. Mga sakit na naranasan niyas ince birth. Ex. colds, mild fever, feeding problems, vomiting, not burping
after feeding, etc.
Fever
3. Allergies – none
 Prompt with common allergies, if needed (aspirin, sulfa, penicillin)
 Make sure you include the reaction
 Also ask about seasonal, environmental, contact and food allergies

4. Current Medications
 Prescribed medications (also determine when started and if any doses have been changed
recently) o Questions to ask about medications
“nandun sa booklet lahat and mga dates kung kalian nag simula. And tuloy tuloy parin
hanggang ngayon. Maintenance niya yun para sa heart disease niya daw pero yung sa
pneumonia wala siyang tinetake na gamut ngayon kasi sa hospital trinitreat daw”

 Name of medication
 Dosage and frequency / change in dosage (make sure you have correct units)
 The way the patient is actually taking it
 The reason the patient is taking the drug
“Prescribed by the doctor naman siya and para daw yun sa heart disease ni patient L.m.
maintenance niya” “yung vitamins naman kaya madami, para mas may more protection si
baby lalo na at may mga sakit siya kaya dapat for more protection”

 How long taking it

CHD medications since july 24,2021 and yung vitamins is since birth
 Does the patient feel it is working yes
 Has the patient had any issues or side effects from it (-)
 Compliance / remember or able to take it (can ask how the patient remembers to take it)
 Creams/ointments (-)
 Eye/ear medications (-)
 Inhalers (-)
 Recent / current antibiotics
Amoxicillin – dahil sa sipon at lagnat
 Clarify any PRN medications for frequency of use
 Over‐the‐counter medications
 Herbal / natural products (including household remedies) o Vitamins
No herbal medicines

Family History:
 add siblings ng parents
Mother Side Father Side
J1.M – (F) J – (F)
J2.M – (F) A – chronic smoker and alcoholic (M) - Father
J3.M – Alcoholic (M)
J4.M – Alcoholic (M)
J5.M – alcoholic - Mother
R.M – Chronic Smoker and alcoholics
 ADDITIONAL QUESTIONS
REVIEW OF SYSTEMS:

Please review everything first. Search on things you are not sure of para smooth ang physical examination
kay baby.

General - Weight, length, head circumference

**yung ibang q’s naulit lang. Fill up na lang Length: 55cm, Head circumference: 24
yung table ng measurements and reflexes on - Maturity
the next pages - Looks healthy or not
- Feeding well or not
- Look well or ill?
- Active/lethargic?
- Obvious malformation?
- check all vital signs and CRT
P: 97
R: 20
Skin, Hair, Nails - skin color
- pallor, jaundice, cyanosis (-)
-Is skin rough or dry? Smooth
-Are nail beds pale? Does it have pink tones or
cyanotic in color?
-Are there certain problems related to hair? Does scalp
has swellings or birthmarks NONE
- rashes sa butt part, dahil sa diapers
- birthmarks on the body butt and shoulders
Head and Neck - anterior fontanelle (is it soft? Is there an increased
intercranial presure on it?)
soft
- skull shape and size
Shape and size is appropriate to his age
-Is there any abnormal movement (s) in neck (-)
-Presence of fever? (Yes/none)
-Is the neck swollen? How about the lymph nodes? (-)
-Is there any enlargement in the thyroid gland (-)
Eyes -Are there any sign (s) of vision problems? (-)
-Are the eyeballs sunken? (-)
-Is there any sign of eye pain? (-)
-Is there a presence of excessive tearing? (-)
- check for red reflex, sclera and coloboma, squint eye
(-)
Ears -Are there any sign (s) of impaired hearing? (-)
-Is there any presence of ear drainage (-)
- low set or simple ears?
- auricular or pre-auricular pits
Mouth, throat, nose and sinuses -Presence of dryness in lips (yes/none)
-Presence of bleeding in gums (yes/none)
-Presence of sore throats and hoarseness (yes/none)
-Presence of nasal obstruction (yes/none)
-Presence of colds (Yes/none)
-Presence of sneezing (Yes/none)
-Presence of nose bleed (Yes/none)
- cleft lip/palate (-)
- neonatal teeth (-)
- nasal flaring (-)
- patency of each nostril(+)
Thorax and lungs -Are there any signs of difficulty in breathing (-)
-Are there signs of SOB (-)
- symmetry of chest movement(+)
- get RR 20bpm
Breast and regional lymphatics -Presence of lumps/ discharge in breast (yes/none)
-Presence of swelling/ tenderness of lymph nodes in
 ADDITIONAL QUESTIONS
axilla (Yes/none)
Heart - Current BP and PR: 97
- Heart murmur Normal
- Femoral pulses (+)
- Apex beat Normal
Peripheral vascular -Presence of edema (hands or feet) (-)
-Presence of change of color or change on the legs of
feet (Yes/none)
Abdomen -Presence of signs of loss of appetite (+)
-Presence of signs of abdominal fullness (-)
- Abdominal distention (-)
- Palpable kidneys? (-)
- Hepatosplenomegaly (-)
Male genitalia -Frequency of urination 3x a day nagpapalit ng diapers
-Presence of signs of pain on the genitalia (Yes/none)
- Undescended testes? (-)
- Ambiguous genitalia? (-)
Anus, rectum -Frequency of bowel movement 2x in a day
-Texture/ color of stool yellowish
-Presence of hemorrhoids (Yes/none)
-Presence of blood in stool (Yes/none)
-Is the patient having diarrhea or signs of constipation?
(-)
- imperforate anus? (-)
Musculoskeletal -Posture (Poor or Stable)
-Presence of swelling, redness, pain, and stiffness of
joints (Yes/none)
- check ortolans’s and barlow’s maneuver
Neurologic -Is the baby lacking in body coordination (-)
- alert or not
- muscle tone
- ability to move arms and legs equally (+)
- reflexes (+)

ANTHROPOMETRIC MEASUREMENTS:

QUESTIONS FOR THE BABY’S REFLEXES: PRESENT MEASUREMENTS: ***complete

dapat dito
Check of all reflexes ay present sa bata? HEIGHT (cm) 55
WEIGHT (cm)
1. Rooting reflex (This reflex starts when the Weight for age
corner of the baby's mouth is stroked or Height for age
touched. The baby will turn his or her head and BMI for age
open his or her mouth to follow and root in the Length
direction of the stroking.) Skinfold thickness- 1”/2.54cm
2. Moro reflex (This reflex usually occurs when a subscapular (cm)
baby is startled by a loud sound or movement. Skinfold thickness- triceps 1”/2.54cm
In response to the sound, the baby throws back (cm)
his or her head, extends out his or her arms and Skinfold thickness- 2”/5.08cm
legs, cries, then pulls the arms and legs back in. quadriceps (cm)
A baby's own cry can startle him or her and Body fat percentage
trigger this reflex) Waist circumference (cm) 30
3. Tonic neck reflex (When a baby's head is Hip Circumference (cm) 34
turned to one side, the arm on that side MUAC (mid upper arm 12
stretches out and the opposite arm bends up at circumference)
the elbow.) Head circumference 24
4. Grasp reflex- (Stroking the palm of a baby's Thoracic Circumference 32
hand causes the baby to close his or her fingers
in a grasp.)
 ADDITIONAL QUESTIONS

5. Stepping reflex (This reflex is also called the walking or dance reflex because a baby appears to take
steps or dance when held upright with his or her feet touching a solid surface.)

GORDON’S
***explore mga answers ni mudra. Huwag tipirin

a. Health Perception and Health Management

 Why does the baby have many vitamins?

For more protections dahil madaming sakit si baby at madaling mahawaan ng mga sakit. Tulad ng ubo at
sipon.
 Frequency and dosages of each medication?
Check gdrive, may medications and doses dun. ty
 What do you (mother) do to keep the baby healthy? To prevent illness?
Compliance sa mga sinasabi ni doctor at sinusunod naming ang weekly at monthly check up ni baby para
maagapan naming agad kung meron bang sakit si baby or wala na. nilalayo din naming siya sa madaming
tao at bihira kaming magkabisita para din hindi mahawaan si baby kung sakali.
 How does the parents manage the baby’s sickness? “Dinadala naming kaagad sa clinic kasi natatakot din
kami na sarilihin naming ang sakit niya kasi wala din akong alam kaya sinusunod ko lang mga payo ni
doctor.”
 Do they self-medicate the baby? Or do they go the the doctor immediately?
 How often does the baby go for a check-up? Monthly check up
 Does the mother think that the baby is healthy? Why or why not?
“Yes, kasi bukod sa diagnosed na sakit niya, ginagawa naming lahat ng mga dapat gawin na sinabi ni
doctor para kay baby. Active naman siya at masayahing bata. Kung titignan mo siya parang walang sakit
sa puso dahil makulit hahaha.”
b. Nutritional and Metabolic Pattern

 How many times a day ang feeding niya every 2 or 3 hours

 Gaano kadalas ang breast milk? Gaano kadalas ang formula? Anong formula milk niya?
every 2 or 3 hours, noon breast milk siya pero ngayon at tapos na ang maternal leave ko, nag fomula milk
na siya ( Similac ) 6 bottles (2oz) in a day
 Kailan siya nagstart mag formula milk? At what week or month? Bakit siya nagformula?
Noong 2 months siya, September 2nd week, dahil tapos na ang maternal leave ko.
 Does the baby drink water? Hindi pa
 Kumakain na ba siya ng foods? Anong food? Sabaw etc Cerelac palang.
 Does the mother think the baby is getting all the nutrients he needs? Oo kasi pinapagatas naman siya kung
nagugutom siya o kapag umiiyak siya
 Food allergies or restrictions none
 Increased or decreased or no change in appetite lately? If meron, gaano ka-’lately’? parang 2 weeks ago pa
nag start na nawawalan siya ng appetite kaya diba napansin mo nung unang punta mo ditto lakas dumede at
medyo malusog pa, tapos ngayon medyo pumayat na siya.
 Medications ulet (huwag na to answerin ulit. Lagay ko lang dito.)

c. Elimination pattern

 How many times a day does the baby voids? none

 Ilang beses siya tuumatae a day? Isa lang? 3x a day
 Blood in urine and stool (-)
 Discharge in genital (-)
 Constipation or diarrhea or kinakabag? Noon, ngayon, gaano ka often (-)
 Any changes in perspiration lately? (-)
d. Activity -Exercise Pattern

 Please describe the usual 24-hr activity of the baby. Mula paggising hanggang pagtulog. All details. Usual
routine ng bata.
Pagkagising niya, papalitan na yung diapers, papaliguan at mag dedede tapos naglalaro na siya. Masaya
siya kapag napapaliguan at hindi siya umiiyak. Very active siya kapag kalaro niya kami tapos maya maya
matutulog na siya tapos manghihingi ulit ng gatas tapos naglalaro ulit siya.
 ADDITIONAL QUESTIONS

 Does the baby crawl in his crib? No

 How does the mother and family members play with the baby? Kinakausap namin siya tapos nilalabas yung
mga laruan niya yung helicopter gusting gusto niya. Gusto niya ang mga laruan niya na tumutunog tunog
 Ilang oras siyang gising in a day? 4-6 hours
E. Sleep -Rest Pattern
 Does patient goes to bed at the same time at night? No. paiba iba kasi minsan may sakit siya kaya maaga o
late siya natutulog dahil hindi siya komportable o kaya kapag nagugutom siya iiyak ulit para humingi ng
gatas kaya hindi pare pareho ang oras pag tulog niya.
 Does patient sleeps about the same amount each day? Yes
 Does patient awakens during the night and is sweating, screaming, and inconsolable? Umiiyak, Gumigising
dahil gutom siya at gusto mag gatas.
 Difficulties or disturbances pag humihingi ng gatas, nanaginip umiiyak
 Write in the number of minutes the nap usually lasts: 120-180 hours
 Ilang beses siya mag nap in a day? 7 up in a day
 On average, how many hours does he sleep in a day? 9 hours
 Does patient seems tired during the daytime? no
 Any changes in sleeping pattern lately no

F. Cognitive Perceptual Pattern

 How long is the attention span of patient when doing an activity? 30 mins to 2 hours
 In what ways the patient express his/her ffelings of happiness or discomfort? Smiling and crying
 Reflexes siguro (don’t answer this na)
 Kaya na bang umupo ng baby without any alalay? no
 Nag-memake sounds na ba siya? Anong sounds, anong words? Laugh and cry. “ma” “te” “didi”
 Nakakabaliktad na ba siya mag isa sa crib yes
 Nag-crawl na ba siya no
 Naglalakad na ba siya na may nakahawak sa kniya not yet
 Describe yung eye contact ng bata good eye contact sumusunod siya sa mga hawak mong object
 Nakakapag recognuize na ba siya ng familiar faces? Sino sino? Yes. Mama, papa, lola na dalawa
 Sense of taste niya. Anong lasa ang mga gusto o ayaw niya
 Sense of hearing, can he recognize sounds ba? Naiistartle bas iya sa loud sounds, nag-papay attention ba
siya sa mother’s voice, sa mga sinasabi ng ibang tao, etc. yes sa all
H. Role -Relationship Pattern
 Paano siya tinanggap ng family nung pinanganak na siya? Parents, siblings, relatives
Nung una ayaw ni mother ni mama ni pt kasi 2nd husband ni mother yung father ni pt l.m. pero as days goes
by, natatanggap nila kasi wala silang ibang dapat gawin para harapin kung ano ang present at kung ano ang
nangyari. Buti daw dahil hindi pinapabayaan ni 2nd husband yung baby at si mother. And they have the full
support naman daw.
 Interaction with family member(s) or others good
 When appropriate: Problems with the baby? Difficulty handling? none
 Kaninong mga tao siya close? Lola na dalawa, mama at papa
 Describe his relationship with his parents and siblings good

I. Sexuality – Reproductive Pattern

Questions Answer
Has the baby been circumcised? When and no
where?
Do you notice any changes to the baby’s no
genitalia?

J. Coping – Stress Tolerance Patterns

Questions Answer
Reasons bakit umiiyak si baby (gutom, pag Gutom, naiinitan, sa maingay
nainjectionan, etc.)
Anong ginagawa ng parents oag umiiyak Kinakarga, sinasayaw, kinakantahan, nilalaro at nilalabas
siya (kinkaarga, nilalaro, nilalabas ng bahay sa bahay
etc)
 ADDITIONAL QUESTIONS

K. Values – Beliefs Pattern

Questions Answer
Religion Roman catholic
Has the baby been baptized? When and St. Stephen church. December 26, 2021
where?
Religious practices involving baby: Nagprepray sila before matulog with baby. Tinuturuan at
ginaguide sa sign of the cross.
For example, Nagpepray ba sila before
matulog si baby, Nagmamass ba sila with
the baby either online or f2f, etc.
Cultural beliefs na ginawa kay baby Yung pag lagay ng sharp objects sa tabi ni baby kapag
natutulog para walang masamang espiritu.
May rosary na nakasabit sa crib ni baby.
May nilalagay na bawang sa crib.
Traditional medicines and herbs na wala
ginagamit kay baby
Naniniwala ba sila sa albularyo? Why or Oo kasi sa mga pamahiinn at yung mga paniniwala talaga
why not? noong unang panahon.
Explore on cultural customs na ‘pagsabi ng Oo daw ginagawa nila yan para daw yung “pwera usog”
pwera usog’, ‘yung parang pinapat ang head mawala yung mga sakit na pwedeng mapunta sakanya ganun.
and katawan ni baby pag aalis na yung Yung “pekkel pekkel” ginagawa din daw nila yun
bisita ganun. Di ko maexplain hahahha.
Baka ‘maannungan’ kasi yung bata ganun;’
and otherssss if meron pa maisip
Ano yung hopes and aspirations ni mother Good health hanggang pagtanda niya at makapagtapos ng pag
para kay baby aaral.

 Clarify bakit maraming vitamins si baby? Prescribed ba lahat? Ano yung hindi ano yung oo?
Lahat ng gamot sa baby book ay prescribed. Maraming vitamins si baby para daw mas malakas ang
proteksyon kay baby lalo na at may mga sakit siya

 Mark red yung mga abnormal sa lab results

Hindi alam ni mother kung ano ang mga abnormal results sa labs kasi wala naman daw nakasulat na normal
values

 Clarify ano yung stage ng each disease

Wala naman daw nabanggit

 What specific CHD ang meron kay pt

Ventricular septal defect

 As in sabay sabay ba na nadiagnose na may pneumonia at CHD siya

No. nauna ang CHD na diagnosed noong 07/24/2021 at sumunod yung neonatal pneumonia after 23 days
na nadiagnosed yung heart disease niya.

 Test result paano naconfirm and pneumonia niya

“Nag pa XRAY si doc. Pero wala akong mapapakitang film or paper nung xray result kasi wala namang
binigay saamin, hindi ko nga alam kung bakit eh. Dapat bang ipa request ko sa hospital yun?”

 Clarify ko lang din, parang walang meds sa drug study to cure his pneumonia, Please follow up on this.
Wala daw siyang meds sa pneumonia kasi yung treatment nun is nagawa daw sa hospital and wala na silang
binigay na mga gamot para dun sa sakit na yun.

**Nona pls check my mesages and reminders nung last meeting. Baka may nalimutan akong iinclude dito.
Thanks :)