Bedside Rounds

ZCMC Ward 8
History Taking and Physical Examination
PEDIATRIC PATIENT
July 08, 2010 02:30 P.M.
Precious, 10 years old residing in Labuan, Z.C
Referral: none
Source and reliability: Grandmother, seems reliable
Chief Complaint
cough
chest pain for 4 days
History of Present Illness
Four days PTA, patient experience cough with
pleuritic pain and fever, brought to the health centre,
medications given such as Amoxicillin drops and
Paracetamol.
History of Present Illness
Three days PTA, there is lysis of fever but cough is still
present. 2 days PTA, patient’s condition worsens. One
day PTA, herbal medications given such as Lagundi,
sambong and calamansi juice. On the day of
admission, patient was crying due to chest pain upon
coughing and this prompted grandmother to bring
patient to the hospital for consultation and findings
shows the need for confinement.
Past Medical History
No previous hospitalization and surgery;
immunization was completed in their respective
health centre. Patient had childhood illnesses such as
measles and mumps. No known allergies. No vitamins
or food supplement taken.
Family History: Father died of cardiac arrest last
August 2009; No familial disease of diabetes,
hypertension, cancer, anemia, epilepsy or mental
illness. Brothers, sisters and grandmother presently
experiences cough
Personal and Social History
Precious was home delivered last July 7, 2000 in
Labuan Z.C., she has 2 brothers and 2 sisters, living
with her grandmother and parent. Unfortunately,
patient wasn’t able to go formal schools due to
financial constraint but patient was taught by
grandmother to read and write. Grandmother is the
one supporting the financial needs of the family by
means of selling vegetables that were planted in their
garden. Patient spent most of her time playing with
the neighbour’s kids and go swimming.
Review of System:
General. Has lost 20%of body weight in the past
month.
Skin. Patient’s skin and nailbed is pale. No rashes,
lumps, sore, dryness or itchness noted.
Review of System:
HEENT. Head, no history of head injury, no headache
or dizziness noted. Eyes, no blurring or doubling of
vision; does not wear glasses or contact lenses; no
pain, redness or excessive tearing of the eye. Ears, no
hearing good; no tinnitus, vertigo, earaches, infection,
or discharges. Nose and sinuses, occasional mild colds;
no nasal stuffiness, discharge, or incidence of nose
bleeds. Throat, no bleeding of gums; no dental check-
up; no sore throat.
Review of System:
Neck. No lumps, goiter, pain, or swelling gums.
Respiratory. Experience pain upon coughing,
presence of white yellowish phlegm. No DOB noted.
Cardiovascular. No known heart disease, blood
pressure not taken, no dyspnea, (+) orthopnea, (+)
chest pain
Review of System:
Gastroinstetinal. There is loss of appetite for the
past month; no difficulty of swallowing noted; regular
bowel movement; no changes in bowel habit; no
nausea, vomiting, constipation or diarrhea; no
abdominal pain noted.
Urinary. No pain or frequency of urination.
Genital. Was not able to assess
Review of System:
Peripheral. No history of leg pain; no edema noted.
Musculoskeletal. No weakness, stiffness, pain or
limitation of motion or activity.
Psychiatric. No history of depression or treatment for
psychiatric treatment.
Review of System:
Neurologic. No fainting, seizures, motor or sensory
loss; memory good.
Hematologic. No anemia; no bleeding; no past blood
transfusion
Endocrine. No know thyroid problem; sweating
average; no symptoms or history of diabetes.
Physical Examination
Precious is a female child, who is thin for her age and
responds weakly to questions. She is somewhat tensed,
with moist, and pale hands. Her hair is not neatly fixed.
Her color is slightly pallid and can’t lie flat on bed
without discomfort.
Physical Examination
VITAL SIGNS
 Temp.: 37.3 o C RR: 52 bpm
 HR: 108 bpm
Physical Examination
 SKIN
 Palms cold and moist, but color slightly pale. No
rashes or lesions noted; Nails without clubbing or
cyanosis. Capillary refill within 2 seconds.
Physical Examination
HEENT
 Head: hair of average texture. Scalp without lesions,
normocephalic or atraumatic.
 Eyes: Conjunctiva pink, sclera white. Pupils
constricting, round regular, equally reactive to light;
Extra-ocular movement intact; disc margin sharp,
without haemorrhages, exudates. No arteriolar
narrowing or A-V nicking. No strabismus, or other eye
abnormalities manifested.
Physical Examination
Ears: wax slightly obscure right tympanic membrane;
Left canal clear; TM with good cone of light; Acuity
good to whispered voice.
 Nose: mucosa pink, septum midline. No sinus
tenderness.
 Mouth: oral mucosa pink. Tongue midline, with no
ulcers or tenderness noted. Tonsils normal; Pharynx
without exudates.
Physical Examination
NECK
 Supple. Trachea midline, no nodules or lesions
palpated or noted.
LYMPH NODES
 No tonsillar, cervical, axillary, inguinal and
epitrochlear nodes
Physical Examination
THORAX & LUNGS
 Thorax symmetric with slight sub-coastal
retractions noted. Lungs resonant. Breath sounds
vesicular, with rales auscultated on the lung lower
lobes. Diaphragms descend bilaterally.
CARDIOVASCULAR
 Carotid upstrokes brisk, without bruits. Apical
impulse discrete and tapping. No systolic and diastolic
murmur.
Physical Examination
BREAST
 Breast pendulous and symmetric. No masses;
nipples without discharge.
ABDOMEN
 Abdomen flat; Bowel sounds active; Liver edge
smooth; Spleen and kidney not well. No costovertebral
angle tenderness.
Physical Examination
GENITALIA
 External genitalia without lesions. Vaginal mucosa
pink. Cervix pink, parous and without discharge.
Uterus anterior midline, smooth, not enlarged. No
cervical or adnexal tenderness. Rectovaginal wall
intact.
RECTAL
 Rectal vault without masses.
Physical Examination
EXTREMITIES
 Warm and without edema. Calves supple, non-
tender.
PERIPHERAL VASCULAR
 No edema at both ankles. No stasis pigmentation or
ulcer.
Physical Examination
MUSCULOSKELETAL
 No joint deformities. Good range of motion in
hands, wrists, elbows, shoulders, spine, hips, knees,
ankles.
Physical Examination
NEUROLOGIC
 Mental status: Tense, weak and less cooperative. Thought
coherent. Oriented to person, place and time.
 Cranial Nerves: Intact.
 Motor: Good muscle bulk and tone. Strenght 5/5
throughout.
 Cerebellar: Point to point movement intact. Gait stable,
fluid.
 Sensory: Pinprick, light touch, position sense, vibration
and stereognosis intact.
 Reflexes: Stable.
Physical Examination
BICEPS TRICEPS BRACHIOR PATELLA ACHILLE PLANT
ADIALIS R S AR
RT 2+ 2+ 2+ 2+ 2+ 

LT 2+ 2+ 2+ 2+/2+ 2+ 
Physical Examination
SCALE OF REFLEXES:
 4+ Very brisk, hyperactive, with clonus.
 3+ Brisker than average.
 2+ Average. Normal
 1+ Somewhat diminished; low normal
 0 No response.