Identification Data

 Name: Rehan mallick

 Age: 7 month
 Sex male
 Religion: Hindu
 Address: 5 no buro shibtala more singur hooghly
 Ward pediatric medicine ward
 Bed No: 6
 Reg No : 120034567
 Date of Admission: 6/02/2024
 Diagnosis: ARI
 Name of the Operation: not done
Chief Complain: on admission baby has respiratory distress with cough and mild fever.

Present History:
 Medical: cough with fever
 Surgical: not applicable

Past History:
 Medical: nothing significant
 Surgical: nothing significant

Birth History:
Prenatal:
 Age of mother- 25 yrs
 Years since marriage – 2 yrs
 Height- 135 cm
 Health problems during pregnancy - nil
 History of Folifer Consumption : taking iron and folic acid tablets as per schedule
 History of Addiction - nil
 Antenatal Check up -4 times
 Immunization – TT1 and TT2 are given
Intra natal:
 Normal Delivery at Hospital- normal deievery
 Baby cried at birth- yes
 Birth weight: 2.6 kg
Post natal:
 Initiation of breast feeding- initiation of breast feeding done just after the deleivery
 History of top-feed- NA
 Meconium & urine passed - yes
 Cord-dry
 Activity- normal
 Jaundice-nil
 Bleeding History- nil
 Congenital Malformation - nil
Developmental History:
Physical:
 Weight: 8.4 kg
 Length: 70 cm
 Head Circumference: 43 cm
 Chest Circumference: 46 cm
 BMI: 17
Motor:
 Gross: early stepping movements done by child
 Fine: hold two toys together and place them from one hand to another
 Cognitive:
 Psychosocial: shows fear of strangers
 Language: vocalize dada mama without no specific meaning
 Spiritual:
Immunization History: baby is fully immunized up to his age
Personal History:
 Behavior: normal
 Personal Hygiene: maintained
 Bathing: done everyday
 Sleeping: normal
 Schooling: secondary school pass
  Elimination: normal
 Dietary History: adequate diet

Environmental History:
 Type of House: pakka
 No. of room: 3 rooms
 Ventilation: well ventilated
 Light : adequate light present
 Water supply: purified tap water
 Pet: not present
 Open area surrounding house: present
\
Family Genogram –

Male

Female

Affected male

Lab Investigation:
 Blood for Hb: 11.5 gm/dl
 Blood for Na+- 136 ,K+- 3.7 mEq/lit , PLT: 2.5 lac
 Blood for LFT: 4.1 mg
 Color Doppler- not done
Treatment: nebulization with 3% NACL 4 hrly, syrup PCM 4ml SOS. Syrup Amoxyclave 2.5 ml TDS.
Normal Diet: breakfast- kichuri. Mid morning- boiled apple. Lunch- rice, sabji, smashed fish. Evening
snacks- dalia. Dinner- milk with smashed ruti

Physical Examination
General Appearance:
 Consciousness: alert
 Posture: normal
 Gait: normal
 Looks: normal
 Color: pink
 Activity: well active
Vital sign:
 Temperature: 99 degree centigrade
 Heart Rate: 120 b/ min
 Respiration: 28 br/min
 BP: 100/60 mm of hg
Anthropometry Measurement:
 Weight: 8.4 kg
 Length: 70 cm
 Head Circumference: 43 cm
 Chest Circumference: 46 cm
 BMI: 17
Respiratory System: cough and mild respiratory distress present
Cardiovascular System: normal
Nervous System: normal
Gastrointestinal System:
 The baby is on
 Passed stool on
 Mouth is clean
 Dentition-Incisor is 2 in upper jaw and 1 in lower jaw in number.
 Peristalsis sound is present.
 Abdomen is soft without any scar
 Infant assessment

Submitted to- SUBMITTED BY-

Madam Rakhi Ghosh. Payel Das
SR. Faculty Teacher Msc(N) 1st year student.
College of Nursing College of Nursing.
Medical college & Hospital Medical College & Hospital.

Integumentary System:
Head is cleaned and rounded, posterior fontanel & anterior fontanel were closed
Ear is normal and wax is present.

Nose is obstructed with secretion.

Neck is short.

Back skin is intact

Chest and abdomen is clean.

Nail is short

Hematologic & Lymphatic system: Lymph gland is not palpable, no palor present.

Musculoskeletal System: All joint are mobile, both upper and lower limb are normal.

Genitourinary System:

The baby passes urine normally.

Both testes is present in scrotum.

Urethral opening is not in normal position.