1. ER Con DRAFT

2. General data L.A 14 month old Female Filipino Roman Catholic Quezon City

3. History of Present Illness CC: Somnolence 6 weeks PTC 5 day hx of cough, colds, fever, No meds. No consult Interval Hx: increase in thirst and polyuria 4 days PTC 4 episodes of vomiting assoc with abdominal pain no fever 1 day PTC increasingly sleepy Poor appetite Brought to ER

4. Review of System General: (-) weight loss Skin: (-) rashes (-) hair loss HEENT: (-) lacrimation, (-) hearing loss, (-) aural discharge, (-) epistaxis, (-) toothache, (-) salivation, (-) sore throat Respiratory: see HPI Cardiovascular: (-)chest pain (-) orthopnea, (-) cyanosis, (-) palpitations

5. Review of System Gastrointestinal: (-) diarrhea, (-) constipation, (-) jaundice Genitourinary: (-) dysuria, (-) hematuria, (-)nocturia Musculoskeletal: (-) bone pain, (-) limitation of movement Nervous/Behavior: (-) tremors, (-) convulsions (-) mood/behavioral change Endocrine: (-) breast asymmetry, (-) pain or discharge

6. Feeding History Mixed diet: eats meat, fishes, poultry, vegetables & fruits which are cut into small pieces combined with formula milk (Promil, 2:1, bottle fed, three times a day)

7. Gestational History G2P1 35 y/o healthy saleslady married to a 36 y/o healthy electrician No infections, no intake of drugs and no complications during pregnancy

8. Birth History APGAR 8,9 No convulsions or hemorrhage, No respiratory or feeding difficulties No congenital anomalies, No birth injury Neonatal History Term 39 weeks, NSD, attended by an OBGYN BW: 3kg

9. Developmental History Walks alone with one hand held Stands alone Speaks 2 other words other than mama and dada Begins to feed with fingers Kisses on request Releases object on request Obeys commands with gestures

10. Past Medical History No food and drug allergies No history of UTI, trauma, surgery, hospitalization, blood transfusion

11. Immunizations done at USTH OPD BCG – 1 dose DPT-3 doses OPV– 3 doses Hepatitis B -3 dose Measles - 1 dose MMR – 1 dose Varicella – 1 dose Hib – 1 dose

12. Family History (+) Hypertension - maternal grandparents No DM, TB, thyroid disease, cancer, kidney disease

13. Socioeconomic History Lives in a 2 bedroom bungalow with family and maternal grandparents Shares a room with parents and sibling Both parents work and provide for the family

14. Environmental History No exposure to cigarette smoke and other environmental pollutants Does not segregate garbage which is collected everyday Drinks mineral water

15. Physical Examination drowsy, in cardiorespiratory distress, well nourished, severely?? dehydrated, ill looking CR 140 bpm, regular; RR 20 cpm, kussmauls breathing pattern; T 37C Ht: 78 cm ( z score 0, normal); Wt: 10 kg ( z score 0, normal) BMI: 16.4 ( z score 0, normal)

16. warm dry skin, decreased skin turgor, no rashes, no edema, no jaundice normocephalic, no active scalp lesions, hair equally distributed Sunken eyeballs, pink palpebral conjunctivae, anicteric sclerae, pupils 2-3 mm ERTL, (+) ROR Midline septum, turbinates not congested, no nasal discharge Dry lips and buccal mucosa, nonhyperemic PPW, tonsils not enlarged, has 4 upper and 4 lower incisors, 2 lower 1 st molars No tragal tenderness, non hyperemic EAC, intact tympanic membrane,AU Physical Examination

17. Symmetrical chest expansion,deep slow labored breathing pattern,(+) intercostal retractions, equal vocal fremiti, resonant on percussion, clear and equal breath sounds Adynamic precordium, AB at 4th LICS MCL, normal S1 and S2, (-) heaves/lifts/thrills/murmurs Slightly globular abdomen, no visible peristalsis, normoactive bowel sounds, tympanitic on all quadrants, liver span: 3.1cm, soft,no tenderness, no masses Pulses weak and equal, no edema, no cyanosis, no clubbing