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A. GENERAL INFORMATION NAME: Verano, Roxanne S.

AGE: 1yr SEX: F RELIGION: Roman Catholic DATE & TIME ADMITTED: 8-24-11 @ 11:00 PM CHIEF COMPLAINT: Fever & Vomiting DIET: Breastfeed ATTENDING PHYSICIAN: Dr. Ayop

IMPRESSION OR DIAGNOSIS: High Grade fever with nasal congestion. BIRTH HISTORY - Baby Verano was born on Aug. 16, 2010 with a birth weight of 4.4lbs via CS in Ozamiz City. HISTORY OF PRESENT ILLNESS - was admitted last Aug 24, 2011 for being febrile (39.8 c) with vomiting PTA with her mother. FAMILY HISTORY - is 2nd of the two children of Vendors.

HISTORY OF PAST ILLNESS - Was admitted a few months ago for LBM, there were no other instances of hospitalization after that.

B. MEDICATIONS KLAZ susp. 4ml PO BID CEFUROXIME (ZINACEF) 250mg q8 IVTT VITAMIN C OD PO E-ZINC OD 1tsp PO RELESTAL 1ml q8

C. GROWTH & DEVELOPMENT NORMAL 1. PHYSICAL Respiration rate varies with emotional state and activity. Chest circumference is larger than head circumference. Legs may still appear bowed. 2. MOTOR Stands alone with feet spread apart, legs stiffened, and arms extended for Stands with arms wide open as if trying to balance her weight. Shows increased rate of breathing after a short run. Body image is similar to that of an adult. ACTUAL

Gait and posture is still unstable when standing, but is able to stand and run.

support. Repeatedly picks up objects and throws them; direction becomes more deliberate. Attempts to run; has difficulty stopping and usually just drops to the floor. 3. LANGUAGE When asked, will point to familiar persons, animals, and toys. Responds to simple questions with "yes" or "no" and appropriate head movement. Speech is 25 to 50 percent intelligible during this period. 4. SENSORY Manages three to four objects by setting an object aside (on lap or floor) when presented with a new toy. Shows or offers toy to another person to look at. Names many everyday objects. 5. SOCIALIZATION less wary of strangers.

Picks up toy and throws directly in front of her.

Runs a short distance and tumbles down when nobody is there to lean on.

Faces then points towards her mother when asked about mama. Nods when agrees on something and shakes head horizontally when disagrees. Labels objects and uses single syllabled words to express a whole thought.

Places glass on her side when the thermometer is presented. Offers glass in exchange of said thermometer. Names glass as tubig.

Social smile is evident. Often imitates adult actions in play. May have a tantrum when things go wrong or if overly tired or frustrated. Imitates me when regulating the IVF. Cries out loud when toy is taken away.

D. PATTERNS OF FUNCTIONING 1. Sleeping Habit- baby Verano sleeps 10-12 hrs. at night and usually naps 1-2 hrs by day. 2. Eating Habit- baby is able to eat lugaw and other soft food 3. Elimination Habit/ Toilet Training- changes diapers between 8-9 am 4. Allergy- none noted 5. Immunization- completely vaccinated.