A 4-year-old Filipino female presented with a 2-day history of cough followed by fever. On examination, she had a temperature of 38.2C, respiratory rate of 44 breaths/min, and heart rate of 125 beats/min. Lung auscultation revealed coarse crackles in both lower lobes with decreased breath sounds posteriorly. She was using accessory muscles to breathe and unable to lie supine due to respiratory distress.
A 4-year-old Filipino female presented with a 2-day history of cough followed by fever. On examination, she had a temperature of 38.2C, respiratory rate of 44 breaths/min, and heart rate of 125 beats/min. Lung auscultation revealed coarse crackles in both lower lobes with decreased breath sounds posteriorly. She was using accessory muscles to breathe and unable to lie supine due to respiratory distress.
A 4-year-old Filipino female presented with a 2-day history of cough followed by fever. On examination, she had a temperature of 38.2C, respiratory rate of 44 breaths/min, and heart rate of 125 beats/min. Lung auscultation revealed coarse crackles in both lower lobes with decreased breath sounds posteriorly. She was using accessory muscles to breathe and unable to lie supine due to respiratory distress.
A 4-year-old Filipino female presented with a 2-day history of cough followed by fever. On examination, she had a temperature of 38.2C, respiratory rate of 44 breaths/min, and heart rate of 125 beats/min. Lung auscultation revealed coarse crackles in both lower lobes with decreased breath sounds posteriorly. She was using accessory muscles to breathe and unable to lie supine due to respiratory distress.
1. General (weight loss or Patient is 4 years old, female and Filipino. Cough started 2 days prior to admission, followed by an on & off fever thereafter. Nausea and vomiting followed gain; fever, chills, night after giving Paracetamol as home remedy. Patient’s temperature is 38.2C 3 hours prior to admission. sweats; mood; stage of development, race, sex; signs of distress; position; cooperative or not; state if irritable, agitated or pleasant; etc.) 2. Head (headache, injury, tenderness, etc.); Eyes (change in visual fields, glasses, blurring, diplopia, pain, loss of vision, tearing, dry eyes, etc.); Ears (change in hearing, tinnitus, discharge, dizziness, etc.); Nose (allergies, sinus problem, obstruction, polyps, sneezing, epistaxis, etc.);Throat (toothaches, loose teeth, bleeding gums, mouth sores, hoarseness, difficulty swallowing, etc.) 3. Integumentary System
4. Respiratory System RR 44cpm, irregular, shallow, breathes through mouth, uses accessory muscle for breathing, unable to breathe in supine position, audible breath sounds (chest pain, dyspnea, within few feet. Auscultation reveals bilateral coarse crackles on lower lobes with decreased breath sounds at posterior area. T 38.2C and SPO2 92% with 02. cough, amount and color of sputum, hemoptysis, etc.)
Patient’s Name / Room No. | 1
5.Cardiovascular System PR 125 bpm (chest pain/ pressure/ tightness, palpitations, orthopnea, paroxysmal nocturnal dyspnea, shorntness of breath, edema, claudication, endurance, etc.) 6. Digestive System Nausea and vomiting (dysphagia, heartburn, ulcer, GERD, indigestion, food intolerance, diarrhea, constipation, abdominal pain, blood in stool, black tarry stools, changes in bowel habits, reduced caliber of stools, hemorrhoids, etc.) 7. Excretory System Stool and urine analysis are also normal. (urgency, frequency, nocturia, dysuria, hematuria, recurrent UTIs, STD, incontinence, etc.) 8.Musculoskeletal System (limitation in movement, stiffness, joint pain, swelling or redness, arthritis, muscle spasms, muscle weakness, etc.) 9. Nervous System
