BON HAROLD T.

BACOL | BSN2

BIOGRAPHIC DATA

Luna Silva is 10 months old, born in April 22, 2019 at San Juan De Dios
Educational Foundation Inc. Hospital who resides at 18 Maryville Homes, Cruz Ext.,
Malibay, Pasay City. Born term to a 32-year- old. Mode of delivery is normal
spontaneous delivery with obstetrical score of G2P2. Her baseline weight is 7.6 kg. and
she is exclusive breastfed.

FAMILY AND SOCIAL HISTORY

Luna’s mother is Karen Ann Silva, a 33-year-old Nurse Educator at Health

Solution Enterprises. She has been married to Jerome Christian Silva for six (6) years, a
33-year- old Wyeth Operator in Makati City. Her family history of disease is breast
cancer on both sides.

IMMUNIZATION

Luna’s immunization is complete with BCG, hepatitis b, pentavalent vaccine three

times, oral polio vaccine three times, inactivated polio vaccine, pneumococcal conjugate
vaccine three times, measles, mumps, rubella two times, rotavirus three times. Luna is
graduated in Expanded Program on Immunization.

REVIEW OF SYSTEM

The baby’s head is proportionate and symmetrical, her eyes are clear and
symmetrical, ears has no discharges, it is symmetrical and responds to sound quickly. The
nose has no presence of discharges and nodules and it is symmetrical. Her skin color is
light brown and appears moist. Her chest and lungs have symmetrical chest expansion, it
has clear and normal breathing sounds. She has a symmetrical abdomen and her upper
and lower extremities are equal. She has a proportionate muscle and no tenderness noted.

ACTIVITY OF DAILY LIVING

She sleeps usually at 7PM and wakes up at 6AM. She eats her breakfast and after
that, they go in their veranda to take some fresh air and sunlight. Around 9AM to 10AM,
BON HAROLD T. BACOL | BSN2

she takes a short nap. When she is awake, she eats her lunch. Luna’s bonding with her
mom is listening to the stories of her brother’s reading. She is having three full meals a
day given by her mother such as the vegetables in the song “Bahay Kubo” along with the
breastmilk in between.

PRESENT ILLNESS

She brought by her mother due to elevated body temperature. Four days prior to
admission, Luna had cold with greenish nasal discharge. Three days prior Luna had an
intermittent fever (37.8). One day prior Luna still had a fever (39.6). Two episodes of
vomiting and decreased appetite. The admitting impression to her is influenza like illness
rule out urinary tract infection.

MEDICATION

She is currently taking Chlorphenamine, Phenylephrine (Disudrin) drops for 0.75

mL, one times a day which relief his clogged and runny nose, itchy and watery eyes.
Help decongestant sinus openings and passages. Cefuroxime (Kefox) every 8 hours 250
mg IV push, to treat his bacterial infection. Ceterizine (Allerkid) drops for allergic
rhinitis such as runny nose, itchy and watery eyes 0.8 ml, three times a day. Paracetamol
(Tempra) as needed for 37.8 temperature and Opigenic Suppository for 38.5, which acts
to reduce his fever and pain. Lastly, D5 IMB (Balance Multiple Maintenance Solution
with 5% Dextrose) 47-48 cc/hour that will run to 10-11 hours. Which provides for
maintenance of fluid and electrolytes for the need of the body and minimal calories.

LABARATORY EXAMINATION

Upon admission diagnostic request was done. Serological test which look for
antibodies in the blood, specifically, NS1 antigen test (nonstructural protein 1) a dengue
test to detect dengue virus that secreted into the blood during dengue infection the result
is NEGATIVE. Complete blood count, his hematocrit level is low 34.8 with the range of
40.0 to 54.0 means that percentage of red blood cells below the lower limit. Hemoglobin
BON HAROLD T. BACOL | BSN2

level is low 10.5 with the range of 12.0 to 17.0 means that blood that carries oxygen from
the lungs is below lower limit.