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1、.,1,By：Group 3 Peng Sijing (Stone) Li Xiaojing (Cathy) Miao Chunmei (Mango) Nie Fengyan (Zara),CASE PRESENTATION PEDIATIRC WARD,.,2,CONTENTS,History,Physical Examination,Introduction,Laboratory Result,MIMS Medication,Nursing Care Plan,Neurologic Examination,.,3,Introduction,GENERAL DATA: p.m.e. , 13
2、 years old , female , Filipino , Christian , born on March 23 , 2004 in Manila currently residing in 270 Kalayaan B . St . Batasan Hills Quezon City , admitted for the first time at FEU-NRMF Medical Center on March 3 . 2018 . CHIEF COMPLAINT : Vomiting,.,4,History,HISTORY OF PRESENT ILLNESS: Four ho
3、urs prior to admission , while swimming in the pool , a container of muriatic acid was noted to be accidentally spilled in the pool , the amount was unknown to the informant . While her cousin moved out of the pool , she submerged herself for a few seconds until she was pulled out of the pool by her
4、 uncle . She accidentally ingested approximately 1 cup of pool water . She then experience dizziness , sore throat , chest pain , difficulty of breathing and body weakness. She then washed herself in the shower. Thereafter, she experienced 2 episodes of non-projectile , non-bilous , non-bloody vomit
5、 of previously ingested food about cup per bout . She was then brought to a nearby hospital and was hooked to oxygen via nasal cannula . They were advised to transfer hospitals due to lack of a pediatric.,.,5,History,HISTORY OF PRESENT ILLNESS:,Few hours prior to admission , upon arrival to the Emer
6、gency Department, she had 1 cpisode of non-projectile, non-bilous, non-bloody vomiting of previously ingested food about 1/2 cup. Still with sore throat, chest pain , difficulty of breathing and body weakness. No dizziness noted. On physical examination, she had symmetrical chest expansion; with int
7、ercostal, subcostal and supraclavicular retractions, crackles all over, wheezes all over and tight air entry. She had episodes of desaturation with oxygen saturation of 80-90%. Complete blood count with platelet count was done which revealed leukocytosis with neutrophilic predominance. BUN, Creatini
8、ne , and Electrolytes were done which revealed normal results. Electrolytes showed normal results. Arterial blood gas showed fully compensated metabolic acidosis. She was advised admission , hence admitted,.,6,History,PAST MEDICAL HISTORY:,Patient had the usual childhood illness such as measles , va
9、ricella ( 2011 ) Patient had the history of Primary Pulmonary Tuberculosis ( 2011 ) ( 6 months treatment,Competed treatment in 2013) No history of seizure , bronchial asthma , dengue , allergies to food and drugs , history of surgery or blood.,.,7,History,FAMILY HISTORY :,Father is 37 years old , Hi
10、gh school undergraduate , Works as a painter , apparently well Mother is 39 years old , High school graduate , Works as a nail technician , apparently well Grandmother has Hypertension and in maintenance of Norvasc 5mg and compliant No other heredo-familial diseases such as diabetes mellitus , kidne
11、y disease , liver disease and psychiatric illnesses .,.,8,History,IMMUNIZATION HISTORY:,.,9,History,NUTRITIONAL HISTORY:,The patient was exclusively breastfed until 6th month of age . She was introduced to complimentary feeding with Cerelac and Gerber on her 6th month and rice with viand was given a
12、t 1 year old . Now , she consumes 4 cups of rice with viand three times day with snacks in between.,.,10,History,HEADSSIRST :,Home life: patient shares a bedroom and bed with her aunt and grandmother Education: she is an 8th grade student with average grades and is a part of the badminton club Abuse
13、: no history of abuse Drugs: with history of alcohol intake , 2 cups of unrecalled alcohol mixture ; no history of prohibited drug intake,.,11,History,HEADSSIRST :,Family: nuclear family , no history of alcohol nor drug abuse Friends: has different groups of friends in every social setting but is ca
14、reful in who she hangs out with Image: sees herself as fat , dresses up like the hypebeast culture Safety: plays volleyball on the streets , no protective gear,.,12,History,HEADSSIRST :,Recreation: she likes to play sports and hangs out with her friends , she is very acive on various social networki
15、ng sites Spirituality: she is a Born Again Christian who goes to church on most Sundays Threats and Violence: she had 1 history of selfharm when she was 11 years old when she cut her forearm with a cutter in school ; no history of running away , cruelty to animals , fighting nor stealing,.,13,PERSON
16、AL AND SOCIAL HISTORY :,History,The patient lives with his parents and siblings in a 1-bedroom 2 story house , well-lit and well ventilated with 1 window . The mother is the primary financial provider . Water source is from Maynilad and drinking water is from a deep well . Garbage is collected twice a week . He sleeps for about 10 hours a day.,.,14,History,OBSTETRIC AND GYNECOLOGIC HISTORY:,Patient had her menarche at 12 years old
