CENTRAL PHILIPPINE UNIVERSITY COLLEGE OF NURSING HEALTH HISTORY FOR PEDIATRIC PATIENT Date: September 22, 2011 Interview:

Durana, K. I. Biographical Data Name: J.C. Age: 4 Gender: M Birth date: February 15, 2007 Religious Affiliation: Roman Catholic

Civil Status: S

VITAL SIGNS TIME 11:30 am II. III. TEMPERATURE 36 C PULSE 98 bpm RESPIRATION 24 bpm BLOOD PRESSURE 90/60 mmHg

Reasons for seeking care (Chief Complaint) Client was admitted kay gina barukoy siya ka ubo as stated by his mother. Present Health or History of Present Illness Two weeks PTA, client was given an antibiotic for cough. After a week, patient had recovered. Three days PTA, patient experienced fever and difficulty of breathing related to coughing Patient was brought to the OPD but was advised for admission. Past Health History Prenatal status As the mother has stated, the pregnancy was planned. After hearing the news of being pregnant, both of the soon-to-be mother and father had a positive reaction. The mother is present at all prenatal check-ups. Mother doesnt drink or smoke and said that there were no complications during her pregnancy. Postnatal status The mother just stayed overnight and by the next day went home with her baby. The baby was bottle-fed and mother reported no feeding problems. Childhood Illnesses Patient has yet to experience any childhood illnesses. Accidents or Injuries Client had once injured/ his elbow but was not admitted as it was only a minor injury. Serious or Chronic Illnesses Client has no serious or chronic illnesses.

IV.

Operations or Hospitalizations Client has never been hospitalized prior to this admission. Immunizations Client has completed his vaccinations by age 1 and just had minor reactions like fever. Allergies Mother stated that patient has no allergies. V. VI. Family History Folks claimed to have a family history of diabetes and hypertension. Review of Systems General Health Overall Health State J.C. is a 4 year old male patient. He appears to be his stated age. He is well-groomed and there is no body odor detected. He is sitting in a chair. Conversant and very active. Shows no signs of distress. Skin Skin is smooth. There is no rash noted. Hair Clients hair is thick and shiny. It has a black color. There is even hair distribution. Hair is free from dandruffs. Head Head is round and symmetrical. Head is proportional to the body. Eyes There is no swelling and discharges noted. Eyes are non-protruding. Eyebrows are black and symmetrical. Ears Ears are bilaterally equal in size and there are neither discharges nor deformities noted. Nose and Sinuses Nose is symmetrical and located midline. No discharges noted. Mouth and Throat Clients lips are pinkish. There is no breath odor noted. Neck Client has a full ROM. Neck is proportional to the body and heads size. Breast There is no rash and discharges noted. Upper extremities Client has a full ROM. Color is evenly distributed. There is presence of IV fluid at right metacarpal vein.

Lower Extremities Has a full ROM. There is presence of scars due to minor injuries due to play. Color is evenly distributed. VI. Developmental History Milestones Motor Development Client had already learned to walk by 10 months. Learned to sit up by 6 months. Dressed self by 2 years with exemption of buttoning clothes. Had skipped the crawling stage according to the mother. Language Had first vocalized mama by the time he was 9 months. Toilet training Achieved bladder control by 2 years and a half and bowel control by 3 years old. Current Development Gross motor skills Child can sit alone, walk alone and climb alone. Client can now also balance with one foot but not for long periods. Fine motor skills Client can feed self but still can be quite messy. Can hold pencil or any writing materials. Language skills Client dont baby talk anymore. Vocabulary has a wider scope. All words are understandable. Personal-social skills Client smiles often. He turns when someone calls his name. Can be quite stubborn if watching television. Toilet training Has full control of his bowel and bladder but still needs assistance when going to the toilet. Nutritional History Client had ate chorizo and corned beef for breakfast, fish and rice for lunch and supper. Client is taking Celine and Neutroplex according to the mother. Had not eaten any junk foods for the past 24 hours. Client is fond of eating eggplant and tambo. Mother views her childs eating habits as healthy because she is also the one that monitors what her childs eating.