I.Personal Data Name: J.

DC Age: 5 months old Sex: Male Address: Birthday: April 14, 2011 Place of Birth: Manila Citizenship: Filipino Religion: Roman Catholic Chief Complaint: Cough Date of Admission: September 10, 2011

II. History of Present Illness Patient was apparently well until 3 days prior to admission. The patient had cough, patient was referred to paediatric pulmonologist, wherein salbutamol nebulisation was given every 4 hours. Few hours prior to admission, patient still have cough now associated with decreased suck and fast breathing. Hence brought with the attending physician and was subsequently advised admission.

Past medical History The patient had no history of hospitalization. No known food and drugs allergies.

Family History The patient had history of asthma on both maternal and paternal side, no other heredofamilial diseases such as hypertension and diabetes mellitus.

Birth and Maternal History Born term to a 33 years old G2P2 mother via caesarean section secondary to myomectomy operation. The patient had no feto-maternal complication noted.

Personal and social History His mother 33 years old house wife, while his father is 40 years old currently pilot. Primary water source comes from purified water. The patient is 2nd in two siblings.

Activities of daily Living

Activities Nutrition And Fluids Elimination / Bowel / Bladder

Before Hospitalization 5-6 bottle of milk everyday. Consumes to 1cup of cerelac. Patient usually change diaper 5-6 times a day. With full of urine. Defecate 2 times a day.

During Hospitalization 3-4 bottle of milk.

Analysis Patient are having difficulty of swallowing. Changing of diaper with urine decreases from 5-6x to 3-4x a day because of the limited oral fluid intake.

Rest and Sleeps

He Usually has 12 Hours of sleep per day he sleeps at around 1pm in the afternoon and woke up at around 4pm. Sleeps again at around 9pm and 6am. He do playing with his brother and playing toys.

he usually defecates 0-1x per day relatives described it as semi-formed formed greenish in colour and moderate in amount. Diaper change 3-4 times a day. He usually have 89 hours of sleep in a day with waking intervals; he doesnt have a regular time for sleeping during his stay. A whole day rest in his bed. And sometimes carried by her mother when his crying.

He has a disturbed sleeping pattern due to his difficulty in breathing, checking of vital signs. The Patients activity was limited due to his present condition. He easily gets tired and usually catch up his breath.
Patient was not able to take a complete bath during hospitalization due to contraptions and for the reason that he easily gets tired.

Activities and Exercise

Personal Hygiene and oral care

Taking a bath 2x per day

He was given partial bath by his relatives

VII. PHYSICAL ASSESSMENT

The patient is carried by his mother conscious and coherent with IVF on right foot. Patient has a noticeable difficulty of breathing due to markedly seen shortness of breath. Patient was irritable. Patients mother was the one able to answer all of the questions. Adventitious breath sounds rales were noted during auscultation. The patient looks weak because of his present illness. Physical Assessment RR: 34 CR: 134 Temp: 36.4

AREA Appearance/ Mental status

TECHNIQUE USED Observation Interview

Skin

observation

NORMAL FINDINGS Relaxed, erect posture; coordinated movements, no body odor or minor body odor relative to work; no breath odor, no distress noted, healthy appearance, cooperative, able to follow instructions, appropriate to situation, understandable. Varies from light to deep brown; from ruddy pink to light pink, no

ACTUAL FINDINGS There were no deformities noted, there were coordinated movements, no body odor, no breath odor, weakness appearance.

ANALYSIS Weakness because of present illness.

Light Brown Skin, no edema freckles, no abrasion.

Normal

edema, freckles, some birthmarks, no abrasions or other lesions, moisture in skin folds and the axillae.

Moisture in skin folds and axillae.

Nails

observation Blanch test

Skull and Face

observation and palpation

Eyes

observation

Convex curvature; smooth texture, intact epidermis, highly vascular and pink in lightskinned clients; dark skinned clients may have brown or dark pigmentation in longitudinal streaks Rounded; smooth skull contour, absence of nodules or masses, symmetric facial features, symmetric facial movements. Skin intact,

Nails are in smooth texture, epidermis is intact, capillary refill is greater than 3 seconds.

Nails havent gotten no trim since hospitalization.

Symmetric, smooth skull contour, absence of nodules or masses, symmetric facial features.

Normal

Skin is

Puffiness of

Ears

observation and Palpation

eyebrows symmetrically aligned; equal movement, skin intact, sclera appears white, shiny, smooth and pink or red conjunctiva, transparent, shiny and smooth cornea, Iris is visible, pupils are black in color; equal in size, round, smooth border, Both eyes coordinated, move unison with parallel alignment. Color same as facial skin, symmetrical, auricle aligned with outer cantus of eye; mobile, firm, and not tender; pinna recoils after it is folded; Normal voice tones audible, Able

intact, eyebrows symmetrically aligned and equal in movement. Pupils are black in colour, equal in size normally 2 to 3 mm in diameter; eyes are coordinated, move unison and parallel in alignment. Puffiness of eyes.

eyes cause by lack of sleep and frequent crying.

Colour is same as the facial skin, symmetrical, auricle is aligned with the outer cantus of the eye, it is mobile firm and not tender, normal voice tones are audible.

Normal

Nose

Inspection and Palpation

to hear ticking of watch in both ears. Symmetric and straight, no discharge or flaring, uniform in color, not tender; no lesions, air moves freely as the client breathes through the nares, mucosa is pink, clear, watery discharge, no lesions; nasal septum intact and in midline, not tender.

Symmetric and straight, with discharge noted nor flaring, color is same as facial skin, there were no lesions,; Nasal septum intact and in midline, No tenderness in maxillary and frontal sinuses.

Patient breathes through the nose with difficulty.

Mouth

observation

Lips is pink in color, soft, moist, smooth texture; smooth, white shiny tooth enamel; tongue is in central position, pink in color, moist, slightly

Pinkish lips, moist. Tongue is pink in color, moves freely.

Normal

Neck

observation

Chest and Back

observation, Palpation, Auscultation

rough,moves freely, smooth with no palpable nodules; Palate is soft, smooth and light pink in color, positioned in midline of soft palate; Tonsils are pink and smooth. Muscles equal in size; head centered, coordinated smooth movements with no discomfort. Lymph nodes not palpable. Trachea central placement in midline of neck; spaces are equal on both sides. Thyroid gland not visible on inspection. Chest symmetric, spine vertically aligned. Spinal column is straight, right and left

Muscles are equal in size; head is centered, smooth and coordinated movements with no discomfort.

Normal

Chest is symmetric; skin is intact; uniform in temperature, no tenderness on the chest and no

Adventitious sounds audible due to presence of thickened mucus in lungs; patient unable to expectorate fully.

shoulders and hips are at same height. Chest wall intact; no tenderness and masses, full and symmetric chest expansion, Percussion notes resonate, except over scapula. Vesicular and broncho vesicular breath sounds.

masses, presence of adventitious sound (rales).

Abdomen

Inspection, Palpation, and Auscultation

Uniform in color, silver white striae, Flat, rounded or scaphoid, no evidence of enlargement of liver or spleen, no visible vascular pattern, Audible bowel sounds, Absence of aterial bruits

Uniform in color, no visible vascular pattern, Audible bowel sounds; normoactive.

Normal

Upper extremities

observation and Palpation

and friction rub, Tympany over the stomach and gas filled bowels; dullness, especially over the liver and spleen or a full bladder, No tenderness. Equal size on sides of body, no contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side, no deformities, no tenderness or swelling. Joints move smoothly.

Equal in size on both sides of the body, no contractures; there were coordinated movements, equal strength on each body side, no deformities and tenderness of bones and joints.

Normal

Lower extremities

observation

Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance, smooth coordinated movement.

Equal in size on both sides of the body. With IV line in right foot.

IV line for therapeutic treatment.

Bronchitis - is an inflammation of the lining of the bronchial tubes, the airways that connect the trachea (windpipe) to the lungs. This delicate, mucusproducing lining covers and protects the respiratory system, the organs and tissues involved in breathing. Bronchitis can be caused by:

Viruses Bacteria Smoking Breathing in certain kinds of irritating chemicals

When the cells lining the bronchi are irritated, the tiny hairs (cilia) that normally trap and eliminate things from the outside stop working. Formation of material associated with irritation (inflammation) also increases; causing the passages to become clogged.

Types Of Bronchitis There are two types of bronchitis:

Acute bronchitis usually lasts only a few days. It is often caused by a viral infection and may begin after you develop a cold or sore throat. It usually produces no long-lasting, harmful effects. Chronic bronchitis is diagnosed when a person has too much phlegm in the airways, which leads to a persistent, productive cough. An individual is considered to have chronic bronchitis if cough and sputum (matter that is coughed up from the lungs) are present on most days for a minimum of three months for at least two successive years, or for six months during one year.

What causes acute bronchitis?

Acute bronchitis occurs most often due to a viral infection that causes the inner lining of the bronchial tubes to become inflamed and undergo the changes that occur with any inflammation in the body. Common viruses include the rhinovirus, respiratory syncytial virus and the influenza virus. Bacteria can also cause bronchitis (a few examples include, Mycoplasma, Pneumococcus, Klebsiella, Haemophilus).

Chemical irritants (for example tobacco smoke, gastric reflux, solvents) can cause acute bronchitis.

What are the risk factors for acute bronchitis? Bronchitis describes inflammation of the bronchial tubes. Smoking is a key risk factor for developing acute bronchitis. Any other illnesses that predispose to similar inflammation also increase that risk (for example asthma patients and patients allergic to airborne chemicals.) Chronic Bronchitis Chronic bronchitis is most common in smokers, although people who have repeated episodes of acute bronchitis sometimes develop the chronic condition. Except for chills and fever, someone with chronic bronchitis has a chronic productive cough and most of the symptoms of acute bronchitis, such as shortness of breath and chest tightness, on most days of the month, for months or years. A person with chronic bronchitis often takes longer than usual to recover from colds and other common respiratory illnesses. Wheezing, shortness of breath, and cough may become a part of daily life. Breathing can become increasingly difficult. In people with asthma, bouts of bronchitis may come on suddenly and trigger episodes in which they have chest tightness, shortness of breath, wheezing, and difficulty exhaling (breathing out). In a severe episode of asthmatic bronchitis, the airways can become so narrowed and clogged that breathing is very difficult

Laboratory

Test Leukocytes Erythrocytes Hemoglobin Hematocrit Thrombocyte Neutrophil Lymphocyte Monocyte Eosinophils Basophils
Analysis

Result 8.31 3.85 11.6 34 640 26.500 62.900 7.700 1.800 1.100

Unit Reference Remarks 10^ 9/l 5.00-10.0 Normal 10^12/ 4.2-6.2 LOW L g/ dl 12.0-17.0 LOW % 40.0-54.0 LOW 10^ 9/ L 150-450 HIGH % 50-70 Normal % 20-40 HIGH % 0-7 HIGH % 0-5 Normal % 0-1 Normal

High Lymphocytes indicates bacterial infection. Monocytes play multiple roles in immune function. Such roles include: (1) replenish resident macrophages and dendritic cells under normal states, and (2) in response to inflammation signals.