SAINT LOUIS UNIVERSITY – SACRED HEART MEDICAL CENTER

Assumption Road, Baguio City, 2600, Philippines

DEPARTMENT OF PEDIATRICS
ADMITTING HISTORY
HISTORY
GENERAL DATA
This is the case of [NAME], years old, male/female, religion, born on [date] in [place], presently residing at [address], admitted for the [number]
time in this institution on [date of admission] under the service of Dr. [name]. The informant is the [mother/father/guardian/patient] with a % reliability.
CHIEF COMPLAINT
[TEXT]
HISTORY OF PRESENT ILLNESS
[TEXT]
PERSONAL AND MEDICAL HISTORY
A. BIRTH HISTORY
I. PRENATAL HISTORY
The mother was ______ years old, G__P__ (___-___-___-___) cognizant of pregnancy at ______ weeks AOG due to amenorrhea from a
previously regular/irregular menstrual cycle, confirmed by pregnancy test done at home. Prenatal care was instituted at _________ AOG by a
______________________. She had a total of ____ prenatal check-ups done regularly/irregularly. UTZ was done are ________ AOG
revealing _______________________________________. There is/are ________________ history of exposure(s) to
VED/smoking/alcohol/radiation.

II. NATAL HISTORY

Patient was born term/preterm via NSVD/LSCS at _________________ by _________________. BW was _________ and BL was
_________. Patient had pink/cyanotic body with good/weak/no cry and limp/active limb movements upon birth. Congenital malformations:
____________________________________. With/Without resuscitive measures done. AS __________________________, BS
____________________________.

III. NEONATAL HISTORY

Patient was breastfed/bottlefed with good with good/poor suck, hospital stay _______________.Umbilical stump fell off after ________
days/weeks with/without signs of infection. Newborn screening results ____________________________________________..

B. FEEDING HISTORY
Patient was breastfed/bottlefed per demand/schedule up to __________________. Complementary milk was given at ____________ with
___________ at ___________ dilution consuming about ______________ per feeding with a frequency of about __________.
Semi solid foods (mashed rice/potato) were introduced at ________________________________________. At present, sample diet includes:

MEAL SAMPLE FOOD ACTUAL CALORIC INTAKE

BREAKFAST
LUNCH
DINNER
SNACK
TOTAL CALORIC INTAKE PER DAY:

The RENI/RDA for children [range] years of age is [text] kcal according to the Food and Nutrition Research Institute. The patient’s daily caloric
intake of [total] kcal is below the recommended energy intake per day based on age.
Multivitamins ___________________________________ were given to the patient at ___________________ old. At present, patient is given
with _________________________________________________________________________.

B. GROWTH AND DEVELOPMENTAL HISTORY

PHYSICAL GROWTH
BIRTH WEIGHT kg
PRESENT WEIGHT kg
PRESENT HEIGHT cm
AT BIRTH (HC, CC, AC) HC: cm CC: cm AC: cm

DEVELOPMENTAL MILESTONES (Data is based from the last Developmental Evaluation of the patient last DATE)
DEVELOPMENTAL DOMAIN DESCRIPTION OF DOMAIN PRESENT
DEVELOPMENT
AGE SCORE
GROSS MOTOR -
FINE MOTOR -
LANGUAGE -
PERSONAL-SOCIAL -
At present, the child is playful and active. There [are no/delays] in areas of the patient’s developmental domain. Behavioral concerns observed
during his developmental examination are as follows:

SOCIAL DEVELOPMENT
Patient sleeps at around [time] in the evening and wakes up at [time] in the morning. Patient interacts with family without discipline problems.

C. IMMUNIZATION HISTORY
Patient’s immunization status is up to date and appropriate to the patient’s age. No adverse reactions were noted.

Vaccine 1st dose 2nd dose 3rd dose Booster Place Reaction
BCG
Hepatitis B
 Pentavalent (DPT+Hep
B+HiB)
TDAP
HiB
Pneumococcal
OPV
IPV
Measles
MMR
Rotavirus
Meningococcal
Hepatitis A
Varicella
Typhoid

D. PAST MEDICAL HISTORY

Patient was apparently well with no history of being diagnosed with bronchial asthma, dengue fever, meningitis, congenital heart disease,
mumps, measles, or chickenpox. Patient had no history of trauma or fall.

E. FAMILY HISTORY
Both parents are presently well. There is a family history of ( ) Bronchial asthma, ( ) Hypertension, ( ) DM, ( ) CA, ( ) Arthritis, ( ) CVD, ( ) CAD,
( ) Malignancy (specify _____________), ( ) twinning, others___________
Father is ___y/o, currently working as a _______, graduate of _________. Mother is ___y/o, working as a ____________, graduate of
_____________. Primary caregiver is the _______. Patient is the ____ child of ____ siblings

F. SOCIAL AND ENVIRONMENTAL HISTORY

The patient lives along a non/congested neighborhood in a ___________ house with _____ rooms with _____ occupants. Source of water for
domestic purposes comes from __________. Drinking water is from ________ and boiled/not boiled for ______ minutes. They have ___ pets. Garbage
is collected regularly every __________. Toilet is _____ type. Hand washing practices:

REVIEW OF SYSTEMS
GENERAL
(-) irritability, (-) lethargy, (-) weight loss, (-) febrile episodes, (-) cold sweats, (-) poor oral intake, (-) weakness, (-) chills
SYMPTOMATOLOGY
INTEGUMENTARY (-) cyanosis, (-) pallor, (-) lesions, (-) dryness, (-) itching (-) rashes, (-) pigmentation
HEAD AND NECK (-) lesions, (-) trauma, (-) swelling, (-) headache, (-) pain, (-) stiffness
EYES (-) tearing, (-) itching, (-) redness, (-) discharge, (-) pain, (-) dryness
EARS (-) discharge, (-) pain, (-) tinnitus, (-) hearing loss
NOSE (-) dryness, (-) congestion, (-) cold, (-) sneezing, (-) obstruction, (-) nasal discharge (-) bleeding
MOUTH AND THROAT (-) dysphagia, (-) soreness, (-) pain, (-) ulcers, (-) hoarseness, (-) dryness, (-) gum bleeding, (-) dental caries
RESPIRATORY (-) cough, (-) sputum, (-) difficulty of breathing, (-) pain, (-) dyspnea, (-) hemoptysis
CARDIOVASCULAR (-) edema, (-) cyanosis, (-) palpitations
(-) change in bowel movement, (-) good oral intake, (-) anorexia, (-) abdominal pain, (-) vomiting, (-) nausea,
GASTROINTESTINAL
(-) constipation, (-) diarrhea, (-) melena
URINARY AND RENAL (-) dysuria, (-) hematuria, (-) nocturia, (-) frequency (-) urinary retention
GENITAL (-) pain, (-) swelling, (-) discharges, (-) tenderness, (-) itch
MUSCULOSKELETAL (-) deformities, (-) swelling, (-) tenderness, (-) cramps, (-) trauma, (-) sprains (-) fractures, (-) stiffness, (-) backache
ENDOCRINE AND
(-) polydipsia, (-) polyphagia, (-) hair change, (-) weight change, (-) temperature intolerance
METABOLIC
HEMATOLOGIC (-) bleeding, (-) bruising
NERVOUS (-) syncope, (-) dizziness, (-) tremors, (-) coordination problems, (-) sensory disturbance

PHYSICAL EXAMINATION
GENERAL SURVEY Awake, conscious, not in cardiopulmonary distress
VITAL SIGNS Blood Pressure: mmHg Heart Rate: bpm Respiratory Rate: cpm Temperature: ºC
Height: cm
SpO2: % at room air BMI: kg/m 2
Weight: kg
ANTHROPOMETRIC Weight-for-age: Z-score: Interpretation:
MEASUREMENTS [plot chart]
Length/Height-for-age: Z-score: Interpretation:
[plot chart]
SKIN No pallor, no jaundice, no cyanosis, warm to touch, good skin turgor
HEAD Equal hair distribution, no scars, no lesions, with flat and open anterior and posterior fontanelles
EYES Non-sunken eyeballs, no periorbital edema, pinkish palpebral conjunctiva, anicteric sclera, no discharge
EARS Equally set ears, no discharge, intact tympanic membrane
HEENT
NOSE Nasal septum at the midline, clear discharge, congestion, no alar flaring,
MOUTH AND pink lips and moist buccal mucosa, no circumoral cyanosis, no tonsillopharyngeal wall congestion, no
THROAT exudates, no enanthem, no gum bleeding
No masses, no supraclavicular and suprasternal retractions, no neck vein engorgement, no cervical
NECK
lymphadenopathy
CHEST AND LUNGS Symmetrical chest wall expansion, no lagging, no retractions, clear breath sounds, no crackles, no wheezes
Adynamic precordium, point of maximal impulse at the fourth intercostal space, left anterior axillary line, no
HEART
thrills, distinct heart sounds, normal rate, regular rhythm, no murmurs
 ABDOMEN Flat, nondistended, normoactive bowel sounds, tympanitic, soft, (-) tenderness upon light and deep palpation
No gross deformities, no edema, pinkish nail beds, full and equal peripheral pulses, with good capillary refill
EXTREMITIES
time of <2 seconds
GENITALIA Grossly male

CEREBRAL
FUNCTION
CEREBELLAR
(-) tremors, (-) nystagmus (-) ataxia
FUNCTION
CN VII: Able to smile, frown, and close eyes with no facial
CN I: Unable to be assessed
asymmetry
NEUROLOGIC CN II: Able to see, pupils are equally round and CN VIII: Able to hear on both ears
CRANIAL reactive to light and accommodation
CN IX, X: Able to swallow, uvula midline, intact gag reflex
NERVES
CN III, IV, VI: Extraocular muscle movement is CN XI: Able to move head from side to side and shrug
intact on both eyes shoulders against resistance
CN V: Able to chew. Intact facial sensation and CN XII: Able to protrude tongue with no noted deviations nor
corneal reflex fasciculations
SENSORY The patient was easily aroused with tactile and acoustic stimulation
MOTOR Active and spontaneous limb movements
NEUROLOGIC
Babinski Reflex: Positive Palmar Grip: Positive
(FOR BABIES)
REFLEXES Moro Reflex: Positive Plantar Grip: Positive
Rooting Reflex: Positive

SENSORY MOTOR REFLEXES

100% 100% 5/5 5/5 +2 +2

. C
100% 100% 5/5 5/5 +2 +2

PROBLEM-ORIENTED MEDICAL REPORT

PROBLEM LIST
PROBLEM #  PROBLEM
1 

S ●
● GS: Awake, alert, conscious, coherent, conversant, not in cardiopulmonary distress with an spO2 of % at room air
● VS: HR: bpm RR: cpm Temp: ºC
● Skin: (-) pallor, (-) cyanosis, (-) jaundice, (-) rashes, warm to touch with good skin turgor
● HEENT: Non sunken eyeballs, pink palpebral conjunctiva, anicteric sclerae, no nasal discharge, moist lips and buccal mucosa
O ● Heart: Adynamic precordium, (-) thrills, (-) heaves, normal rate regular rhythm, (-) murmur
● Chest/Lungs: Symmetrical chest wall expansion, no lagging, no retractions, clear vesicular breath sounds, no crackles, no wheezes,
no ronchi
● Abdomen: Flat, nondistended, normoactive bowel sounds, tympanitic, soft, no tenderness on upon light and deep palpation
● Extremities: (-) gross deformities, full and equal peripheral pulses, capillary refill time is < 2 seconds, (-) edema
A
● Complete Blood Count with Platelet Count
DIAGNOSTICS
● Coronavirus Disease-19 Reverse transcription- Polymerase Chain Reaction
● IV fluid:
P THERAPEUTICS ● Medications:
●
DISPOSITION
WOF

NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATIONS

Prepared by: Checked by: Approved by: Noted by:

, MD
Pediatric Clerks-in-Charge License No.: MD
Pediatric Intern-in-Charge Pediatric Resident-in-Charge License No.:
Pediatric Consultant-in-Charge