DA NANG UNIVERSITY OF MEDICAL TECHNOLOGY AND PHARMACY

FACULTY OF NURSING

MEDICAL REPORT – PEDIATRIC DEPARTMENT

March 13, 2024
Student: NGUYEN HOA VAN CHI
Student code: 2153011017

A. General information
1. Full name: TRAN MINH NHAT 2. Age: 58 months old
3. Gender: Male
4. Address: Binh Hien ward, Hai Chau district, Da Nang City
6. Date and time of admission to the Hospital: 7:43 March 5,2024
7. Date and time of admission to the Department: 8:05 March 5,2024
8. Date and time of making a medical record: 9:00 March 11, 2024
9. Next of skin: Dinh Thi Mai Loan (mother)

B. Professional section
1. Chief complaint: Dyspnea, vomiting
2. History of Present Illness (HPI)
According to the patient’s mother, the patient’s symptoms began 1 day prior to
admission with the onset of coughing a lot
3. History
Obstetric History:
 The patient was the third child, PARA: 3003
 Full-term, uncomplicated vaginal delivery. Birth weight: 3.7kg. No
congenital defects.
 The patient cries immediately after being born. No asphyxiation
 The mother gained 10kg during pregnancy. Not getting sick during
pregnancy.
Developmental History:
Appropriate developmental status for his age:
 Mental: alert, non-energetic
 Verbal: can speak at 17 months old. Currently, he can speak in full
sentences, easy-to-understand idea
 Social: able to talk, and cautious when interacting with strangers. The
patient currently attending kindergarten.
 Gross motor: The patient can sit at 8 months old, stand at 9 months old,
and walk at 13 months old. No difficulty walking, able to eat well.
 Fine motor: playing mobile games, and watching videos on a smartphone
Nutrition:
 Breastfeeding within 1 hour after birth
 Mixed (breast milk and formula milk)
 The patient is completely breastfed within the first 6 months.
Breastfeed 8–10 times a day, each time approximately 150-180
milliliters.
 Weaning at 20 months of age
 Type of formula milk used: unknown. In the seventh month, the
patient was still breastfed and supplemented with formula milk.
 Lost 1kg at 18 months old due to illness (Pneumonia)
 According to his mother, currently, the patient eats 3 meals at the
kindergarten. The patient has 5 meals per day (3 main meals and 2
snacks)
- Breakfast: such as bread, soup, noodles, etc.
- Lunch: rice with main dishes based on the school’s menu such as fish,
pork, chicken, beef,.. and vegetables, and soup though. And he has fruits
for dessert.
- Dinner: the same as lunch but changes the main dishes (change the
protein, the vegetables, and fruits)
- Snacks: randomized such as yogurt, fruits, cake, sweet dessert, etc
- Every day, the patient has 2 boxes of 180 milliliters of fresh milk.
Past Medical History:
  Pneumonia (at 18 months old). Treated at Hai Chau Medical Center
 Allergic rhinitis occurs when the weather changes ( especially when the
weather turns cold)
Past Surgical History:
No known surgical history.
Medications:
No known medications or supplements dietary use.
Vaccination status:
 Full extended vaccine packet offered when born
 No additional vaccinations
Allergies:
 No history of allergies to foods, drugs, or other allergens.
 The patient has Allergic rhinitis when the weather changes.
Family History:
 All members on both father’s and mother’s side have sinusitis and allergic
rhinitis.
 No family history of hereditary diseases or any significant medical
conditions
 Both parents are healthy, no smoking, no alcoholic.
Social History: the patient goes to the kindergarten from Monday to Friday
every week.

4. Review of Present
4.1. Review of Systems
 General: The patient is alert and conscious with normal gait and posture
without any visible respiratory distress. No fever, night sweats, weight loss.
 HEENT: Denies ocular drainage and irritation. Denies hearing loss or
difficulty swallowing.
 Cardiovascular: No chest pain, palpitations, or edema reported. No history of
murmur or arrhythmias
  Pulmonary: Denies any shortness of breath. Lung sounds: wheeze, coarse. No
history of COPD, asthma, or OSA ( obstructive sleep apnea)
 Gastrointestinal: Abdominal dull pains at the umbilical region, nausea,
vomiting. No signs of abdominal distention, or diarrhea. No changes in bowel
habits
 Genitourinary: Decreased urine output. Dark yellow urine. Denies dysuria,
hesitancy, or frequency. No hematuria. No discharge.
 Musculoskeletal: Within normal range. No joint pain, stiffness, or limited
range of motion was reported. Denies recent fractures, strains, or sprains.
 Hematologic: No known bleeding disorder
 Neurologic: No bowel, or bladder incontinence. No history of seizures. No loss
of consciousness
 Psychiatric: No impairment of mental health.
 Immunologic: No history of immune-related disease.
4.2. Physical Exam
 General: The patient is alert, conscious, and oriented. There are no signs of
pallor, cyanosis, edema, respiratory distress, jaundice, or rash. No peripheral
lymphadenopathy. No thyroid enlargement.
 Vital signs
o Pulse 115 bpm (normal range)
o Respiratory rate: 26 (normal range)
o SBP: 100 mmHg (90%ile); DBP: 60 mmHg (90%ile)
o Temperature: 36.8oC
o SpO2 : 98%
 Developmental status
Patient’s Percentile Reference range
measurement
Height 111cm 75%ile
Percentile:
Weight 16kg 25%ile
> or =5th to < 95th
BMI 13.2kg/m2 5%ile
 Head: No signs of trauma, deformities, or mass. Symmetrical without hair loss.
 Eyes: Pupils are equally round, reactive to light, and intact to extraocular
movements. No noted redness or swelling.
 Ear Nose Throat
o Clear tympanic membranes without effusion. No tenderness of the
external auditory canal.
o No note nose swollen. The nose discharges a small amount of white
mucus.
o Moist mucus membrane. No visible ulcers, lesions, or swelling on the
gums or palate. No noted cyanosis, glossitis, or candidiasis. Oropharynx
without tonsillar enlargement.
o Lips are without pallor
 Pulmonary
o No signs of chest retraction, tachypnea, dyspnea, accessory muscle
breathing
o No chest deformity
o Productive cough ( phlegms is white and thick, its amount approximately 3-
4 milliliters per expectorated)
 Chest:
No masses, pectus excavatum/carinatum
 Cardiovascular
o No notes of angina, dyspnea
o Regular rate and rhythm
o Pulse: 115 bpm; SBP: 100 mmHg; DBP: 60 mmHg
o Peripheral pulses are equal and symmetrical
o Apex located at the left 5th intercostal space.
o S1, and S2 are heard even and clear
o No murmur, rubs, or gallops
 Abdominal
o Abdominal dull pain at the umbilical range (FRS-2 points)
o
  Genitourinary:
o No signs of hematuria. No dysuria, hesitancy, or frequency.
o Ballot kidney (-)
o No bladder distention
o No ureteral tenderness.
o Normal external male genitalia with no discharge.
o The amount of urine within 24 hours is about 1.0-1.3 milliliters. The
urine’s color is dark yellow.
 Musculoskeletal: No clubbing or cyanosis of digits. Normal capillary refill.
o Upper extremity: Normal symmetry; skin warm, without splinter
hemorrhage or scars. No notes of swelling or tenderness of both arm.
o Lower extremity: Symmetry appreciated, without scars, or masses. No
signs of edema, tenderness, or swelling.
 Skin: No rashes or ulcers. No notes of subcutaneous bleeding.
 Neurology
o Cranial nerves are intact. Focal neurological deficits (-)
o Meningism symptoms (-): No nuchal rigidity, headache, nausea or
vomiting, constipation.
 Psych: Appropriate memory, judgment, and insight
 Rectal: Not assessed

5. Paraclinical result
Laboratory
 Complete Blood Count
o RBC: 4.21 1012/L (normal 4.3 – 5.8) – Low
o HGB: 11.9 g/dL (normal 14.0 – 16.0) – Low
o HCT: 33.3% (normal 38 – 50) – Low
o MCV: 79 fl (normal 84 - 92) – Low
o MCHC: 35.8 g/dl (normal 32.2 – 35.6) – High
o WBC: 17.1 109/L (normal 4 - 10) – High
o NEU: 15.0 109/L (normal 1.2 – 6.8) – High
 o LYM: 1.8 109/L (normal 1.2 – 3.2)
o MONO: 0.3 109/L (normal 0.1 – 0.9)
o %LYM: 10.6% (normal 21 – 50) – High
o %MONO: 2.1% (normal 4 – 8) – High
o %NEU: 87.3% (normal 41 - 74) – High
Imaging
 Chest X-ray: Bilateral hilar opacification image
6. Prescription

7. Summary
A 58-month-old male patient was admitted to the hospital with symptoms of dyspnea,
and vomiting on 1 day of the disease.
 References

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