Carla Jean E.

Gajo Pediatrics I
2021-0017 April 1, 2023

Pediatrics I SGD 2

3/31/2023 1:00 pm
Identifying Data
LMR is a 6-year-old female, Roman Catholic, residing in Palm Heights, Brgy. Doña Imelda,
Quezon City who came in for a checkup for issuance of medical clearance for school admission.
The patient’s informant is his mother, AR, who works as a computer designer.
Source and Reliability. Self-referred; seems reliable since she is one of the main caregivers.

Chief Complaint
Issuance of medical clearance for school admission

History of Present Illness

The patient is a 6-year-old female who consulted for a routine check-up. The patient's
mother reports that she is generally healthy and has no current complaints or symptoms.

Birth and Maternal History

Patient was born to a non-smoker 29-year-old, G1P1 (1-0-0-1) mother. AR reported that
the pregnancy was planned, and she had regular prenatal check-ups since her first month of
pregnancy. She was given folic acid and iron and denied any complications and maternal medical
conditions during her pregnancy. AR was in labor for 12 hours without complications. LMR was
delivered 38 weeks AOG via normal vaginal delivery. Birth weight, and APGAR score was
unknown. Patient and her mother were discharged at Cardinal Santos Hospital where she was
born.

Immunization History
Based on the birth book brought by LMR’s mother, she received BCG, DTaP, OPV, Hib,
Hepa B, and Rotavirus vaccines from her pediatrician at Cardinal Santos Hospital. 1 dose of BCG
was given at birth; 4 doses of DTaP (last dose was given last April 2, 2018 simultaneously with
OPV and Hib vaccines); 3 doses of Hepa B (last dose was given last July 3, 2017); 2 doses of
rotavirus (given on March 4 and May 6, 2017).

Feeding/Nutritional History
LMR was purely breastfed from birth until 6 months. After 6 months, she was also given
formula milk while being breastfed. She stopped breastfeeding at 3 years old. Currently, LMR
eats 4x a day; during breakfast, lunch, afternoon, and dinner. She consumes meals comprised of
either meat or vegetables with rice such as tinola. She likes sweet foods like chocolates and fruits
shakes and has no dislike for a specific food. LMR’s mother reports that she and her husband
prepare and cook the meals that they consume. Source of food is from the market. Patient was
reported to have good appetite and have no problems in feeding in general. She is currently taking
Ceelin vitamins.
Developmental History
LMR’s mother reports that she can speak in sentences, write well, and read two letter
words. She had no problems with bed wetting ever since she was 3 years old and she can dress
by herself, pee and poop alone, eat without help, and play with other children.

Past Medical History

Allergies: LMR has no known allergies
Illnesses: Informant denied any illnesses and abnormalities
Accidents: No accidents and injuries
Previous hospitalizations/Surgical: No past hospitalization records and prior surgery

Family History
No family history of hypertension, diabetes, asthma, dengue, hyperlipidemia, tuberculosis,
cancer, heart or kidney diseases, anemia, epilepsy, congenital diseases, or mental illnesses

Personal and Social History

LMR lives with his mother and father in a 2-bedroom unit within a compound in Palm
Heights, Brgy. Doña Imelda, Quezon City. The compound where their home is located is noted to
be clean, not crowded, no animals roaming around, and has a playground where LMR plays.
Source of drinking water is from a refilling station. LMR has her own room but her mother reports
that she likes to sleep with them. LMR’s mother works as a computer designer while her father
works as an accountant. Both of her parents are her primary caregivers and are currently working
from home. None of the members of the household are smokers or alcohol drinkers. LMR attends
online pre-school. She has friends from online pre-school whom she meets personally and plays
with. She also sings, dances, and is currently into the K-pop group Blackpink. Patient was reported
to have 9 hours of sleep and a 2/3-hour nap in the afternoon.

Review of Systems

General: No significant weight loss, fever, body weakness or fatigue.

Skin: No rashes, bumps, itching, dryness, eczema, or lesions.
Eyes: Vision good. No lacrimation, discharge, blurred vision, itchiness, and double vision.
Ears: Hearing good. No hearing loss, ear pressure, discharge, pain and ringing.
Nose: No nasal congestion, hay fever, sinus trouble, discharge, nosebleed and nasal pain.
Throat and Mouth: No lesions, swelling, sore throat, toothache, and gum problems.
Neck: No swollen lymph nodes.
Respiratory: No cough, difficulty breathing, and dyspnea.
Cardiovascular: No chest pain and palpitations.
Peripheral Vascular: No leg pain, cramps, and swelling of extremities.
Gastrointestinal: Bowel movement good; no constipation or diarrhea. No vomiting, indigestion,
dysphagia, distension, and bloating.
Urinary: No dysuria, hematuria, nocturia, incontinence, urgency, frequency, and infection.
Endocrine: No excessive thirst. No heat or cold intolerance
Musculoskeletal: No muscle pain, joint pain, weakness, and stiffness.
Neurologic: No headaches, dizziness, syncope, numbness, tingling, seizures, tremors, and
balance problems.
Hematologic: No anemia, easy bruising, bleeding tendencies, and blood transfusion.
Psychiatric: Mental health is good. Patient was described as a jolly child.

Physical Examination
LMR is a well appearing 6-year-old female. She is awake, alert, not in distress, and
appropriately dressed for her age. Patient is in the 90th percentile for weight and while between
the 75th and 90th percentile for height which is at most in the 85th percentile. This means that she
weighs 90% and measures 85% more than children of the same age. On the other hand, her BMI
is above 85th percentile which implies that she is overweight.

Vital signs: Temperature 36.8C. Respiratory rate is 30 cycles per min. HR is 110bpm.

Skin: No pallor, rashes, lumps, masses, or edema.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: No thinning and normal distribution of hair. No signs of trauma.

Eyes: Pinkish palpebral conjunctiva; anicteric sclera. Pupils are round, equally brisk and reactive
to light. No discharge or redness.

Ears: Normal ear position; symmetrical in size, shape, position, and appearance. Intact tympanic
membrane. No tragal tenderness and discharge

Nose: No discharge, discoloration, fracture, or redness.

Mouth: No dental caries. Normal teeth, tongue, and tonsils.

Neck: No lumps, masses, or lymph nodes.

Chest:
Thorax and lungs: Trachea midline. Lungs are symmetric; no deformation and clear breath
sounds.
Heart: No chest wall deformity, cyanosis, and edema. Adynamic precordium. JVP not taken. No
murmurs, masses, or distinct heart sounds.

Abdomen: Abdomen is globular in shape. Non-tender, normoactive bowel sounds, and no

organomegaly.

Genitalia: No swelling, discharge, or discoloration.

Rectal: No hemorrhoids, lumps, or masses.

Extremities: No edema or deformities.

Reflex: Patient can walk well, run, hop, and can go up and down the stairs.

Anthropometrics

Body weight: 25kg

Body length: 120 cm
BMI: 17.4 kg/m2

Figure 1. Physical Growth Chart for 2-20 years of age

Final Impression
LMR is a 6-year-old female with an unremarkable physical examination. Her growth and
development have been normal however, further evaluation is needed for the patient’s reading
ability. In addition, she also needs to receive necessary vaccinations (Varicella, IPV, PCV,
Measles, Influenza, and Covid vaccines) to bring her up to date with her recommended
vaccination schedule.

Anticipatory Care
Follow-up check up on April 3, 2023, for routine vaccination.
Eat healthy food and keep rehydrated.
Lessen sweet foods.
Reading interventions that might help include phonics program, breaking down words
into syllables, or having her read out loud more often.