Dr. Jose P.

Rizal School of Medicine Appetite (good/picky eater):

Xavier University – Ateneo de Cagayan Usual food intake:
Department of Pediatrics Amount per day
Junior Clerkship Breakfast:
Lunch:
Name: Dinner:
Date of Submission: July __, 2017 Vitamins:
Preceptor: Dr. Leo G. Notario, DPPS Type (brand):
Dosage & Frequency
Case Protocol
JULY __, 2017 Neonatal History
INFORMANT (Ask regarding abnormalities during the neonatal period such as
cyanosis, pallor, jaundice, convulsions, hemorrhage, respiratory or
RELIABILITY feeding difficulties congenital abnormalities, birth injury. Include the
age of onset and management done)
Spontaneous respirations after birth?
PATIENT’S PROFILE -
APGAR Score:
Duration of hospital stay:
General Data
Complaints, hospitalizations during 1st 28 days?
Name: ______ Sex/Age: ________ Religion: _____________
DOB: _____________ Status:________
Medical History
Educational Attainment:______
Childhood illnesses: (Cough, Colds, Fever, Measles, Chickenpox)
Address:
________________________________________________________
__________________________________________________
_______________________________________________________
Date and Time of Admission: __________________
History of surgery:
Date and Time of interview: ___________________
________________________________________________________
Allergies/food intolerance:
Prenatal History
_______________________________________________________
Age of mother : _______ OB Score: G_P_ (_ _ _ _)
Prenatal checkup at AOG of _________ at
Family History
_____________________________________________
Parents Mother Father
Medications taken during pregnancy:
Age:
_________________________________________________
Occupation:
Maternal Health during pregnancy:
Educational attainment:
____________________
Health status:
Past medical history: ____________________
If not living:
TT vaccine: _________________________
Age of death:
Other: ______________________________________
Cause:
Alcohol: ___________________________
Siblings
Smoking: ____________________________________
Number:
Names:
Birth History
Ages:
AOG at birth: _________ Delivered via: _______________
State of health:
Presentation: ______________ Duration of labor: _______________
Family illness or anomalies:
at ________________________ attended by ________________
(Contagious, hereditary, acquired)
Condition at birth: ______________________ (e.g. crying, pink,
(DM, HPN, Asthma, Cancer, Endocrine prob.,
apgar, wt); Weight: ______________ Anthropometric
mental/neurologic disorder, etc)
measurements: Ht: _____ HC: _____ CC: ________ AC: __________
Socioeconomic/environmental history:
Past medical history: _______________________________
Place & Nature of dwelling:
Complications: ___________________
# of persons living:
Living situation:
Nutritional History
House: __________________________________
Type of feeding (BF or formula):
Toilet: ___________________________
Frequency per day:
Water source: ___________________________________
Duration of feeding:
Electricity: __________________________________
(If not breastfed):
Reasons:
Economic circumstance: ____________________________
Formula used:
Source of Funds:
Dilution:
Working members:
Amount per day and per feed:
Cup/bottle fed:
Exposure to cigarette smoke:
Complementary foods
Living with whom:
Age introduced:
Environmental pollutants (type & duration):
Frequency per day:
House
Usual food intake:
 Garbage disposal: Head hold 3 months
Sewage disposal: Roll over 5 months
Water source:
Sitting 7 months
Electrical source:
Pull to stand 9 months
Pets:
Walk independently 12 months
Type of neighborhood:
Run, pivot, walk backwards 15 months
Ventilation:
Vaccination Walk upstairs with rails, throw ball 18 months
Type of Doses Date Place Untoward Jump with both feet, walk 24 months
Vaccine Reactions downstairs
BCG Jump forward, pedal tricycle 30 months
Hep B1 Ride a tricycle 3 years
Hep B2 Hop 4 years
Hep B3 Skip 5 years
DPT 1 Climb, run, swimming, skip rope 6-7 years
DPT 2
DPT 3 B. FINE MOTOR SKILLS
OPV 1
Skill Average Patient age
OPV 2
OPV 3 Unfisted hands 3 months
Measles Reach and hold objects 4 months
Others Midline hand play 5 months
Transfer objects between hands 7 months
Developmental/Behavioral History: Thumb-finger grasp/pinch 9 months
(Young Children 1-5yrs) Throwing or casting objects 12 months
Dental eruption: Spontaneous scribbling 15 months
Urinary continence: Imitate stroke on paper 18 months
Start & end of toilet training: Imitate vertical lines 24 months
Number of hours of sleep: Draw circle with series of 30 months
Activity during the day: perseverating lines
Defecation per day (and char. of stool): Draw circle or body with 2 body 3 years
Voiding per day: parts
Draw a cross 3.5-4 years
(Middle Childhood 6-11 yrs)
Draw a square 4-4.5 years
School performance:
Draw a triangle 5 years
Tanner’s Maturity Rating:
Copy letters, reverse letters, 6 years
person in 12 parts
(Adolescence 10-20 yrs)
Home: Know right and left sides 7 years
Education:
Eating behavior of habits: C. LANGUAGE
Activities:
Drugs: Skill Average Patient age
Sexual: Expressive (E)- Cooing, 3 months
Suicidal Ideation: Receptive (R)- Alert to human
Tanner SMR: voice
Menstrual history: E- Babbling 6 months
Menarche:
R- Localize sound
Duration:
Amount: E-mama/papa non specific 9 months
Dysmenorrhea: R- Understand “no”
E- single words with meaning 12 months
Skill Average Patient age R- Follow 1 steo command
Dress under supervision 3 years Two worded phrases, follow 2-step 24 months
Dress independently/correctly 4 years commands
3-4 worded telegraphic sentences, 3 years
Do simple errands, help in house 5 years
understands prepositions
chore
Complete sentences, understand 4 years
Dress up completely, tie shoe laces 6 years concept of size
Understand concept of time, 5 years
Developmental Milestones: follow 3-step commands
A. GROSS MOTOR SKILLS Verbalize emotions, Follow 3-serial 6 years
command
Skill Average Patient age
 Percent of Weight for Height:
PROBLEM 1: ____________________________________ ________________

History of Present Illness: DEGREE OF STUNTING

________________________________________________________ Percent of Height for age: ________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________ SKIN
________________________________________________________ Inspection
________________________________________________________ Brown skin tone
________________________________________________________
________________________________________________________ Acyanotic
________________________________________________________ No Jaundice
________________________________________________________ No abnormal pigmentation
________________________________________________________ No discoloration
________________________________________________________ No excessive sweating
________________________________________________________ No bruises
________________________________________________________ Lesions (Pruritic, red macular lesion with
___ erythematous border in varying
stages of development)
PROBLEM 2: ______________________________________ Palpation
Moist skin
History of Present Illness: Smooth texture
________________________________________________________ Good skin turgor
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________ NAILS
________________________________________________________ Inspection
________________________________________________________ Acyanotic nail beds
________________________________________________________ No clubbing
________________________________________________________ Palpation
________________________________________________________ Smooth texture
________________________________________________________ Capillary refill time <2 seconds
________________________________________________________
________________________________________________________ HEENT
________________________________________________________ Head & Scalp
________________________________________________________ Inspection
___ Hair is black, long and with uneven distribution
No flakes and nits on the scalp
OBJECTIVE Palpation
Physical Examination Skull is symmetric
GENERAL SURVEY: Anterior and Posterior fontanels are closed
________________________________________________________
________________________________________________________ Face
________________________________________________________ Inspection
__ Symmetric nasolabial fold
Palpation
VITAL SIGNS No masses and lesions
Blood Pressure : _____________
Pulse Rate: : _____________ Eyes
Respiratory Rate : _____________ Inspection
Temperature : _____________ Both eyes:
Symmetrical eyes & eyebrows
ANTHROPOMETRICS No scaling of eyebrows
Length : _____________ No periorbital edema
Head Circumference : _____________ No excessive tearing
Chest Circumference : _____________ Pink bulbar and palpebral conjunctivae
Abdominal Circumference : _____________ Anicteric sclerae
Actual Weight : _____________ (+) optic blink reflex
BMI : ______________ (+) ROR
(+) Direct and consensual reflex
DEGREE OF WASTING Pupils equally round and reactive to light;
measuring 3mm constricting to 2 mm
 ABDOMEN
Ears Inspection
Inspection Flat abdomen
Symmetric auricles, the pinna is at the level of No prominent veins
the inner and outer canthus of the eyes No visible pulsations
Turns head to listen to voices No visible peristaltic movements
Minimal cerumen on ears Umbilicus at the midline with no swelling and
Palpation redness
No masses and lesions on auricles, mastoid Auscultation
region Bowel sounds = 24 clicks/min
Percussion
Nose Tympanitic in all quadrants
Inspection Palpation
Symmetric external nose Non-palpable liver
Nasal septum in the midline Spleen and kidneys not palpated, patient was
No nasal flaring not cooperative
No bleeding
No lesions GENITOURINARY
Nasal mucosa pink
Watery nasal discharges FEMALE GENITALIA
Inspection
Throat (Mouth and Pharynx) No redness, rashes noted on external genitalia
Inspection No bruises and lesions
Moist lips ANUS
Pink oral mucosa Inspection
No ulcers and lesions in oral mucosa Located midline
Tongue at the midline No fissures
No nodules, ulcerations & lesions of the tongue No rectal prolapse
No swelling and redness of tonsils
PERIPHERAL VASCULAR
Neck Inspection
Inspection All extremities warm with good capillary refill (1
Neck supple second)
No lesions and swelling on the neck No edema on face, neck & extremities
Trachea midline No varicosities
Palpation
Palpable non-movable smooth around 5mm in Palpation
size submental lymph nodes Pulse Rate: 152 beats/min
Brisk amplitude of arterial pulses
CHEST and LUNGS Radial 2+
Dorsalis Pedis 1+
Anterior and Posterior Thorax Popliteal 1+
Inspection Brachial 2+
Respiratory Rate : 28 cycles/min
Thorax symmetric MUSCULOSKELETAL SYSTEM
No chest deformity Inspection
No retractions (Subcostal & intercostal) No deformity
No lumps and masses No trauma
Palpation No limitation in range of motion of all joints
Symmetric chest expansion
Percussion NERVOUS SYSTEM
Resonant on all lung fields Sensorium- awake and alert
Auscultation Motor – no spasticity or flaccidity
Vesicular breath sounds on all lung fields Good muscle bulk and tone
5/5 on all extremities
CARDIOVASCULAR SYSTEM Sensory - responded to light touch
Inspection Cerebellum- coordinated movements
Heart Rate : 152 beats/min No tremors
Adynamic precordium
Palpation Cranial Nerves
No thrills and heaves II,III • Pupils equally round and
Auscultation reactive to light
Normal heart rate and regular rhythm III, IV, VI • Extraocular movements of both eyes
Distinct S1 at the apex & distinct S2 in the base are intact
No murmurs heard • No ptosis
 • Convergence and  ________________________________
accommodation not assessed ______________________________
V • Motor: No facial  ________________________________
asymmetry ______________________________
• Sensory: Respond to light
touch sensation Preventive/Education:
Corneal reflex  ________________________________
not assessed ____________________________
VII • Able to smile and close  ________________________________
eyes _______________________________
VIII • Able to respond to sound  ________________________________
created ____________________________
IX, X • Able to swallow
• Gag reflex not assessed
XI • Able to turn head from side
to side
XII • No tongue deviation
• Midline protrusion of the
tongue

Reflexes
Biceps Triceps Brachioradialis
Patellar Achilles
Right 2+ 2+
2+ 2+ 2+
Left 2+ 2+
2+ 2+ 2+

Reflexes
Palmar Grasp Reflex Negative
Plantar Grasp Reflex Negative
Moro Reflex Negative
Tonic Neck Reflex Negative
Rooting Reflex Negative
Babinski Reflex Positive

Assessment

Impression: _____________________________________

Differential Diagnosis:
Diagnosis Rule-in Rule-out
1.

2.

3.

Plans:
Diagnostics:
Confirmative:
________________________________________________________
____
Definitive:
________________________________________________________
__
Therapeutics:
Therapeutic