PORTFOLIO-1
NAME of patient Amanuel Belay
AGE: 4year 4 month
SEX: Male
WARD: pediatric ward
DATE OF ADMITTION: -04/06/15
WEIGHT:14.5kg
HEIGHT:101cm
BED NUMBER:2/3
History Of Present Illness
This is a 4yr and 4-month-old male child. presenting abnormal body movement of one episode
which it was generalized tonic-colonic type , involving both upper and lower extremity
followed by up rolling of eye, dropping of saliva, loss of consciousness. He had a history of one
episode of non- projective vomiting of ingested matter and one episode of watery diarrhea also
had high grade intermittent fever of one day.
Past Medical History
He has history of similar illness as his age of 2 year which was stops by its self.
Past Medication History
Before coming to St peter hospital, he was admitted at near by health center and took
paracetamol
250 mg and he was in oxygen 2liter
Family History
His mother and grandmother have similar illness and presenting
Other NO history of
Trauma
Cough
No yellow or discolored eye or skin
Physical Examination
HEENT: - Pink conjunctiva, no discoloration of eye, ear or nose.
LYM: -
CHEST: - no chest deformity, resonance sound on percussion, no added sound.
CARDIAC: - S1 and S2 well heard.
ABD: flat and abdomen moved with respiration, no tenderness.
GUS: -
MSS: -
CNS: -
Allergy: - No allergy
Subjective Data Objective / vital sign
Abnormal body movement P/R: - 117
Fever Spo2: - 94
Vomiting Temperature: - 37
Diarrhea W/T: - 14.7 H/T: - 101 cm
Laboratory finding
Urine analysis
Physical examination PH= 6.5, Gravity =1.05
Chemical examination all are negative albumin, glucose, lactose, bilirubin, blood
Microscopic RBC= 0-4, WBC= 2.5, Epetilial cell few
PORTFOLIO 2
NAME of patient: Hiwot kassay
AGE: 1year 3 month
SEX: Female
WARD: pediatric ward
DATE OF ADDMITION: 12/04/15
WEIGHT: 5kg
HEIGHT:64cm
BED NUMBER:1/3
History Of Present Illness
This is a 1year and 3-month female child was relatively healthy one week back after that she had
abdominal distension with high grade intermittent fever for one day duration. and had four
episodes of yellow watery diarrhea for one day duration also cough of two-day duration, which
was dry non whooping and none barking type. She had fast breathing rate which lasts for two
days. Sha had history of loss of appetite, body swelling on leg after abdominal distension.
Past Medical History
No past medical history. But when she delivered she was very low birth wight of 1kg.
Past Medication History
No medication history
Family History
No familiar history
Other NO history of
Vomiting
No yellow or discolored eye or skin
Immunization: - she was immunized according to her age.
Nutrition: - breast feed for 2 months, start formula after 2month and start cow milk after 6
month
Sunlight exposure: - exposed
Developmental history (gross motor) :- cannot sit with out support
Economic status: - 3 people live in one room without separated kitchen and toilet
Anthropometry value
Wight=5kg
Hight=64cm
MUAC=10CM
WFH=-3
WFA=2-3
HFA=-3
Vital sign
Pulse rate=134
Respiratory rate=46
Pso2=99%
Temperature=38.4
RBS= 124mg/dl
Investigation
Urine analysis
Chemical examination Microscopic
Leukocyte =+1 RBC= 5.7
Blood= traced WBC=9.12
Nitrate=positive epithelial cell=many
Ketone=positive
CBC
WBC= 6.6
RBC=4.93
HGB=12.8
HCT=38.3
MCV= 77.7
Neutrophile=38.2
Lymphocyte=54.9
Monocyte=6.4
Assessment / problems
P1= SAM
P2= febrile UTI
TREATMENT
Antibiotic
On the first day ampicillin 50 mg/kg iv QID
Gentamicin 29.5mg/kg iv daily
PCM 125mg suppository PRN
Ceftriaxone 220 mg iv bid
DTP:
pharmaceutical care plan
monitor and evaluation
