Professional Documents
Culture Documents
ROUNDS
Group 2
Suller, Armida
Sunga, Mary Anne
Suntay, Ma. Lourdes
Sy, Jennifer Paula
Tabuena, Gertzie Dara
Tacujan, Karina Michaela
Tad-y, Mia Marie
Talusan, Patrick Jason
CLINICAL ASSESSMENT
Clinical Assessment
E.B., 11 month old male
Area I, Lot 37, Block 52, Brgy. Sto. Niño, Sapang
Palay, San del Monte City, Bulacan
Informant: Mother
Reliability: 85%
History of Present Illness
• watery nasal discharge
14 days PTC
• cough productive of whitish sputum
• decrease in appetite
7 days PTC
• A> Viral bronchitis
• P> Salbutamol 2 mg/5 mL, 2.5
mL q6h for 7 days; Increase
fluid intake cough improved
• yellowish nasal discharge
Consultation
Review of Systems
General survey Gastrointestinal
– active – (-) vomiting
– (-) weight loss – (-) change in bowel movements
– (-) food intolerance
Cutaneous Genitourinary
– (-) rash – light yellow urine
– (-) pigmentation – (-) discharge
– (-) edema of the hands and feet
HEENT
– (-) excessive lacrimation, Nervous
nasal or aural discharge – (-) vomiting
– (-) epistaxis – (-) convulsions
– (-) weakness or paralysis
Cardiovascular
Musculoskeletal
– (+) fainting spells – (-) swelling
– (-) limping
Respiratory
– (-) difficulty of breathing Hematopoietic
– (-) pallor
– (-) easy bruisability
Past Personal History
Gestational History
– 21 y/o
– G2P1 (1-1-0-1)
– healthy
– good nutrition
– no infections
– no intake of drugs
– 9 months gestation
Past Personal History
Birth History
– term
– NSD
– physician attended the birth (Ospital ng
Maynila
– birthweight 7.5 lbs
Past Personal History
Neonatal History
– spontaneous respiration, no required
resuscitation
– acyanotic
– no pallor or jaundice
– no convulsions
– no hemorrhage or feeding difficulties
Past Personal History
Feeding History
– Breastfed for 1 month
– Age weaned: 1 month; reason: due to
galactocoele
– Formula: Bona
– Medications: multivitamins
– Food intake: (+) solid foods at 6 months
– fed every (hours)?
– consumes (bottles of milk in 24 hours)?
Past Personal History
Growth and Development
- Talked: 6 mos (“mama” and “papa”)
11 mos (other than “mama” and “papa”)
- Sat alone: 9 mos
- Stood alone: 10 mos
Past Personal History
Immunizations
– BCG (1 mo)
– DPT, OPV (2,3,and 4 mos)
– Measles (9 mos)
• Siblings:
– Older brother died at 2 days old
Skin
– fair, good turgor, no rashes, no scars, no edema
Head
– equal distribution of hair, normocephalic and atraumatic,
anterior and posterior fontanels are closed, no abnormal
swelling or depressions, no overlapping sutures
Eyes
– pink palpebral conjunctiva, anicteric sclerae, pupils ERTL,
no opacities or abnormal discharge
Physical Examination
Ears
– no abnormal discharge, no inflammation or foreign
bodies
Nose
– patent nares, no flaring of alar nasi, midline septum
Oral Cavity
– pink, moist buccal mucosa, (+) upper and lower central
incisors, no lesion or hemorrhages, non-hyperemic
posterior pharyngeal walls, tonsils not enlarged
Physical Examination
Neck
– no venous engorgement, no rigidity, no thyroid enlargement, no
abnormal masses, no palpable lymph nodes
Thorax
– symmetric chest expansion, no retractions, head circumference
> chest circumference
Lungs
– no lagging, clear breath sounds
Heart
– adynamic precordium, AB 4th left ICS MCL, no lifts heaves or
thrills, base: S2>S1, apex: S1>S2, no murmurs
Abdomen
– globular, umbilicus midline, no visible veins or abnormal
pulsations, normoactive bowel sounds, nontender, no masses,
tympanitic
Physical Examination
Extremities
– pulses regular, full and equal
Neurologic Examination
– General: alert, normal facial movements
– Motor: symmetry of arm and leg movements, normal muscle
bulk, no atrophy, adequate muscle strength for age, good grasp
of objects
– Cerebellar: no tremors and not hypotonic
– Developmental reflexes: (+) palmar and plantar grasp reflex, (-)
Moro, rooting and tonic neck reflex
– Primitive postural reflexes: (-) placing and stepping reflex, (+)
supporting reaction, (+) Landau reflex
DIFFERENTIAL DIAGNOSES
ACUTE BRONCHITIS
• inflammation of the trachea, bronchi, and
bronchioles
• 90% are viral in origin
• Prevalent throughout the world
• One of the top 5 reasons for childhood
physician visits
• Peak age: <2 years; 9-15 years old
ACUTE BRONCHITIS
Production of
symptoms
discussion
Predisposing Factors:
–Viral URI
– Allergic Rhinitis Ostia Patency
–GERD
– Immunologic Defects
– Ciliary dysfunction Mucociliary Clearance
-Viral URI
Inflammation of the sinus ostia
Absorption of O2
Negative pressure
Tracheobronchial epithelium
– Purulent sputum
Discussion
• Physical Examination:
– Absent or low grade fever
– Upper respiratory signs
– Coarse breath sounds
– Coarse and fine crackles
– Scattered high pitched wheezing
Treatment
• No real treatment for rhinosinusitis
– Caused by rhinovirus (101 sero types)
• Symptomatic treatment
– Fluids, proper nutrition
– Fever: antipyretic (Paracetamol)
– Nasal Obstruction: nasal decongestants
(Xylometazoline HCl)
– Rhinorrhea: Antihistamines (Loratidine), Ipratropium
bromide
– Sore Throat: mild analgesics (acetaminophen)
– Cough: Antihistamines (Loratidine)
Treatment
• Acute viral bronchitis
– No real treatment
– Self- limited
– Shifts in position: facilitate pulmonary
drainage
– Bronchodilators: Salbutamol
Treatment
• cool mist vaporizer or humidifier
– help decrease bronchial irritation
• Cough suppressant
– dextromethorphan
– Risk suppuration and insipissated secretions
• Guaifenesin
– loosen secretions
FAMILY ASSESSMENT
FAMILY GENOGRAM
Eugene Carl,11mos
FAMILY PROFILE
FAMILY MEMBER AGE/SEX CIVIL RELATIONSHIP TO EDUCATIONAL OCCUPATION STAYING WITH
STATUS THE HEAD OF ATTAINMENT THE
THE FAMILY FAMILY?
Carlo Asentista 25/M M Son of Rodolfo and High School Waiter Yes
Lorena Graduate
Stairs
Bathroom
Living Room
Kitchen
Bedroom And Dining Area
Windows
Bed
Attic
ENVIRONMENTAL PROFILE
House Two storey, owned by grandfather
Type Mixed (concrete, wood and GI sheets)
Number of bedrooms 2 bedrooms, kitchen, living room, 1 bath
and toilet
Order and cleanliness Minimal clutter
Floor area Living room doubles as sleeping quarters
Flooring Tiles and wood
Ventilation 4 windows
Electric supply Meralco
Lighting Good
Lighting facilities Fluorescent lights
ENVIRONMENTAL PROFILE
Water NAWASA (local water district)
Drinking water Tap water
Toilet type Manual flush (buhos-type)
Refuse disposal Not segregated
Garbage collection Disposable diapers only every Mondays
Incineration
Drainage Open
Vermin/insects Mosquitoes, mice, cockroaches, no vermin
control used
Pets: 5 dogs, 12 puppies, 2 pigs and poultry
Neighborhood Located near a barangay health center, St.
Martin, school and public market
Accessibility Dirt road
ASSESSMENT
POSITIVE POINTS NEGATIVE POINTS
Sufficient and clean water source Presence of stray dogs and cats
No vermin control
TOOLS OF ASSESSMENT
APGAR
SCREEM
APGAR:
Adeline
TOTAL 7
APGAR:
1. Sino-sino ang mga nakatira sa inyong tirahan? Ano
ang iyong relasyon?
- Sa mga manugang kadalasan ay pinanasyal na
tulong.
a. In the future, what is the family’s primary goal?
- Their primary goal is to have all their kids finish
school and have a good, stable job.
b. Do all the members work together towards these
goals/desires? How? If not, what seems to be the
hindrance for working together?
- Yes, usually by communicating openly to each
other.
c. Is there any history of alcoholism, gambling, drug
abuse/dependency, domestic violence? Has something
been done to address this problem?
- Yes, specifically alcohol and drug use. In the past,
both Carlo and Adeline used Marijuana and shabu but
was not addicted to it. Carlo is an occasional drinker of
alcohol.
d. To what organization does the family belong to?
- El Shaddai
SCREEM:
Parameter Strength Weaknesses