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Pediatric Clinical Correlation Chronic Case

Pediatric Clinical Correlation Chronic Case. Group 3 (Lim, Harold- Lipana , Kirk). General Data. Date of Admission: February 11, 2011 Name: Vitug , Junsen Barcas Age: 16 Sex : M Birthdate: December 24,1994

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Pediatric Clinical Correlation Chronic Case

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  1. Pediatric Clinical CorrelationChronic Case Group 3 (Lim, Harold- Lipana, Kirk)

  2. General Data • Date of Admission: February 11, 2011 • Name: Vitug, JunsenBarcas • Age: 16 • Sex: M • Birthdate: December 24,1994 • Address: Blk. 27, Lot 10, Palmera Spring II, Novaliches, Caloocan City • Nationality: Filipino • Religion: Roman Catholic • Informant: Father and Patient • Reliability: 80%

  3. Chief Complaint “namamaga ang kanang hita” ( swelling of the right thigh )

  4. History of Present Illness

  5. Immunization History • Completed EPI from health center until 9 months of age • Past Medical History • Primary complex(treated)- 6 months of HRZE • Varicella- 9 years old • Intracerebralhemorrhage: 2008 (factor VIII infusion); resolved • Family History: • Hypertension -Grandparents • Hemophilia A – Both siblings • Brain tumor- Maternal grandmother • Prostate cancer- Maternal grandfather

  6. Developmental/ Behavioral History • Home: Second of 3 siblings, lives with his parents and brothers in Caloocan • Education: currently 3rd year High School Student in Bagumbong High School in Caloocan; average academic performance • Eating Behavior: good appetite, no specific food preference, five basic food groups present in daily meals • Abuse: no reported sexual abuse or observed signs of physical abuse • Activities: goes out with friends, stays home often • Drugs: denies illicit drug use, non alcoholic beverage drinker, non smoker • Sexual: denies sexual contact/activity; has not had romantic relationships • Safety: wears seatbelt when riding cars; commutes often • Suicidal ideations: no suicidal ideations/attempts • Family: good interpersonal relationships with family members • Image: good self esteem/desires opposite sex • Recreation: goes to malls with family, use of internet, texts often • Spiritual: regularly goes to Sunday mass • Threats/Violence: no imposed harm to self or others; no reported threats

  7. Socioeconomic/Environmental profile • Patient lives in a 1-storey house with one bedroom with his immediate family. • Source of drinking water from a water station and bathing water is from NAWASA. • Garbage is collected once a week. • The family owns a pet dog. • Father is a smoker.

  8. Review of Systems

  9. Physical Examination

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