PEDIATRIC SAMPLE DATABASE/CASE
Patient Data
Name: T.S
Age: 6mo 7d/F
Birthday: 9/15/2023
Source: Patient’s mother
Reliability: 97%
Chief Complaint: dyspnea
History of Present Illness
3 months PTA, the patient presented with dyspnea and a dry cough, no further association of
other symptoms, prompting evaluation at our institution and was given Salbutamol- Asmalin
syrup Q6 for 7 days. Initial investigations revealed bilateral pneumonia on chest radiography.
Subsequently, another consultation outside our institution was done and another X-ray was
performed which revealed as bronchopneumonia. Consultation to her attending physician was
done and was given Co-amoxiclav drops, administered twice daily for seven days, but terminated
prematurely (given 4x only) due to hypersensitivity reactions, notably facial erythema. Another
consultation at a local hospital led to a subsequent course of Clarithromycin, dosed twice daily
for seven days, was completed, yielding partial alleviation of the dry cough.
2 months PTA, the patient experienced nocturnal dyspnea, prompting consultation at a local AP.
Management included a regimen of salbutamol-ipratropium nebulization every six hours for five
days, accompanied by Cetirizine drops twice daily for seven days and Montelukast 200 mg oral
mixed in 5 ml distilled water once daily at bedtime for two weeks. Providing partial relief of dry
cough. Subsequently, she was given Cotrimoxazole drops were initiated twice daily for seven
days, but symptom exacerbation ensued as claimed.
In the interim persisting dyspnea prompted further consultation, resulting in an extended course
of Montelukast oral solution now in a higher dose 400mg in 5ml distilled water ODHS for one
month, providing partial symptomatic relief. 18 days PTA patient consulted another AP and was
given Cefixime drops, administered twice daily for seven days, was discontinued after five days
due to worsening symptoms as claimed.
Five days PTA, the patient sought care from another healthcare provider, receiving a prescription
for Azithromycin drops to be administered twice daily for 5-7 days, though only four days of
treatment were completed.
Six hours prior to admission to this institution, the patient underwent evaluation by a
pulmonologist, who initiated investigation with chest radiography and prescribed an inhaler.
However, the patient was subsequently admitted to our facility for further management.
,Past Medical History
The patient has no reported history of childhood diseases, tuberculosis (TB), or exposure to TB.
There is no documented history of previous hospital admissions. Notably, the patient denies any
known food allergies. However, there is a documented drug allergy to co-amoxiclav.
Antibiotic History: Co-amoxiclav, Clarithromycin, Cotrimoxazole, Cefexime, Azithromycin
Family Medical History
Family medical history reveals that on the maternal side, there is a negative history of
hypertension (HPN), diabetes mellitus (DM), cancers, and heart disease. However, there is a
positive history of bronchial asthma (BA). Similarly, on the paternal side, there is no reported
occurrence of hypertension, diabetes mellitus, cancers, or heart disease. Nevertheless, there is a
positive history of bronchial asthma.
Prenatal history
Throughout the pregnancy, prenatal check-ups commenced three months prior at the
lying-in clinic and were consistently attended more than ten times. The expectant mother
adhered to a regimen of regular supplementation, including multivitamins, to support maternal
and fetal health. Fortunately, the pregnancy proceeded without any complications, reflecting a
smooth and uneventful course. Importantly, the expectant mother maintained a healthy lifestyle
by abstaining from smoking and refraining from consuming alcoholic beverages throughout the
duration of her pregnancy, contributing positively to maternal and fetal well-being.
Birth history
The patient is delivered from a 23-year-old G3P3 (3002) mother, delivered at term via
normal spontaneous vaginal delivery (NSVD) at the lying-in facility. Her obstetric history includes
three pregnancies: the first in 2018 resulted in the birth of a male child who is currently living.
The second pregnancy, in 2021, unfortunately ended in tragedy with the loss of a female child
due to pneumonia.
Neonatal history
Following delivery, the neonate experienced no complications, demonstrating a smooth
transition to the extrauterine environment. Feeding was established without any notable
difficulties, indicating adequate suckling reflex and feeding coordination. Furthermore, the
newborn underwent routine screening tests, all of which yielded normal results. Both the
newborn screening test and the hearing screening test returned within normal limits, affirming
the absence of any concerning developmental or auditory abnormalities.
, Developmental history
At two months of age, developmental milestones were observed as the infant began to
exhibit the ability to smile responsively, indicating emerging social and emotional awareness. By
three months, further advancements were noted as the infant demonstrated increased neck
strength and control, evidenced by the capability to hold their head upright independently.
Additionally, signs of teething became apparent, marking the onset of dental development. By
four months, developmental progress continued as the infant achieved the milestone of rolling
over, indicative of enhanced motor coordination and muscle strength.
Feeding history
The patient received breastfeeding exclusively for the initial two months of life; however,
this practice ceased as the mother resumed studying. From the age of two months to four
months, the patient was fed Nestogen Classic formula, with no significant fluctuations in weight
observed during this period. Subsequently, at four months, the patient transitioned to Nestogen
1 formula, maintaining a consistent weight trajectory. Between four months and six months, the
patient continued with Nestogen 2 formula, again experiencing no notable changes in weight.
From six months onward to the present, the patient has been receiving Bonamil formula,
prepared with six scoops in 180 milliliters of water. Additionally, water intake commenced at six
months of age and has been ongoing since then, although initially administered in small amounts
via drops.
Immunization history
The patient received vaccinations in accordance with the immunization schedule
provided by the local health center. Shortly after birth, the patient received one dose each of the
Bacillus Calmette-Guérin (BCG) and Hepatitis B vaccines, both administered at the local health
center. Subsequently, a series of vaccinations were administered at the same facility, including
three doses of the pentavalent vaccine (Penta) and three doses of the oral polio vaccine (OPV).
Additionally, one dose of the inactivated polio vaccine (IPV) was administered at the local health
center. The patient also received two doses of the pneumococcal conjugate vaccine (PCV) at the
same facility. However, as per the available records, there is no documentation indicating the
administration of the measles, mumps, and rubella (MMR) vaccine to the patient at the local
health center.
Personal and social history
The patient resides in a household where both parents have been together for seven years,
fostering a stable family environment. They live with their parents and an older brother, aged
five, who is currently attending school. The father, aged 23, balances roles as a construction
worker and a student, while the mother, also 23 years old, fulfills responsibilities as a
homemaker and a student as well. Despite their varied roles, both parents actively engage in
their child's upbringing and education. The father serves as the primary provider for the family,
Patient Data
Name: T.S
Age: 6mo 7d/F
Birthday: 9/15/2023
Source: Patient’s mother
Reliability: 97%
Chief Complaint: dyspnea
History of Present Illness
3 months PTA, the patient presented with dyspnea and a dry cough, no further association of
other symptoms, prompting evaluation at our institution and was given Salbutamol- Asmalin
syrup Q6 for 7 days. Initial investigations revealed bilateral pneumonia on chest radiography.
Subsequently, another consultation outside our institution was done and another X-ray was
performed which revealed as bronchopneumonia. Consultation to her attending physician was
done and was given Co-amoxiclav drops, administered twice daily for seven days, but terminated
prematurely (given 4x only) due to hypersensitivity reactions, notably facial erythema. Another
consultation at a local hospital led to a subsequent course of Clarithromycin, dosed twice daily
for seven days, was completed, yielding partial alleviation of the dry cough.
2 months PTA, the patient experienced nocturnal dyspnea, prompting consultation at a local AP.
Management included a regimen of salbutamol-ipratropium nebulization every six hours for five
days, accompanied by Cetirizine drops twice daily for seven days and Montelukast 200 mg oral
mixed in 5 ml distilled water once daily at bedtime for two weeks. Providing partial relief of dry
cough. Subsequently, she was given Cotrimoxazole drops were initiated twice daily for seven
days, but symptom exacerbation ensued as claimed.
In the interim persisting dyspnea prompted further consultation, resulting in an extended course
of Montelukast oral solution now in a higher dose 400mg in 5ml distilled water ODHS for one
month, providing partial symptomatic relief. 18 days PTA patient consulted another AP and was
given Cefixime drops, administered twice daily for seven days, was discontinued after five days
due to worsening symptoms as claimed.
Five days PTA, the patient sought care from another healthcare provider, receiving a prescription
for Azithromycin drops to be administered twice daily for 5-7 days, though only four days of
treatment were completed.
Six hours prior to admission to this institution, the patient underwent evaluation by a
pulmonologist, who initiated investigation with chest radiography and prescribed an inhaler.
However, the patient was subsequently admitted to our facility for further management.
,Past Medical History
The patient has no reported history of childhood diseases, tuberculosis (TB), or exposure to TB.
There is no documented history of previous hospital admissions. Notably, the patient denies any
known food allergies. However, there is a documented drug allergy to co-amoxiclav.
Antibiotic History: Co-amoxiclav, Clarithromycin, Cotrimoxazole, Cefexime, Azithromycin
Family Medical History
Family medical history reveals that on the maternal side, there is a negative history of
hypertension (HPN), diabetes mellitus (DM), cancers, and heart disease. However, there is a
positive history of bronchial asthma (BA). Similarly, on the paternal side, there is no reported
occurrence of hypertension, diabetes mellitus, cancers, or heart disease. Nevertheless, there is a
positive history of bronchial asthma.
Prenatal history
Throughout the pregnancy, prenatal check-ups commenced three months prior at the
lying-in clinic and were consistently attended more than ten times. The expectant mother
adhered to a regimen of regular supplementation, including multivitamins, to support maternal
and fetal health. Fortunately, the pregnancy proceeded without any complications, reflecting a
smooth and uneventful course. Importantly, the expectant mother maintained a healthy lifestyle
by abstaining from smoking and refraining from consuming alcoholic beverages throughout the
duration of her pregnancy, contributing positively to maternal and fetal well-being.
Birth history
The patient is delivered from a 23-year-old G3P3 (3002) mother, delivered at term via
normal spontaneous vaginal delivery (NSVD) at the lying-in facility. Her obstetric history includes
three pregnancies: the first in 2018 resulted in the birth of a male child who is currently living.
The second pregnancy, in 2021, unfortunately ended in tragedy with the loss of a female child
due to pneumonia.
Neonatal history
Following delivery, the neonate experienced no complications, demonstrating a smooth
transition to the extrauterine environment. Feeding was established without any notable
difficulties, indicating adequate suckling reflex and feeding coordination. Furthermore, the
newborn underwent routine screening tests, all of which yielded normal results. Both the
newborn screening test and the hearing screening test returned within normal limits, affirming
the absence of any concerning developmental or auditory abnormalities.
, Developmental history
At two months of age, developmental milestones were observed as the infant began to
exhibit the ability to smile responsively, indicating emerging social and emotional awareness. By
three months, further advancements were noted as the infant demonstrated increased neck
strength and control, evidenced by the capability to hold their head upright independently.
Additionally, signs of teething became apparent, marking the onset of dental development. By
four months, developmental progress continued as the infant achieved the milestone of rolling
over, indicative of enhanced motor coordination and muscle strength.
Feeding history
The patient received breastfeeding exclusively for the initial two months of life; however,
this practice ceased as the mother resumed studying. From the age of two months to four
months, the patient was fed Nestogen Classic formula, with no significant fluctuations in weight
observed during this period. Subsequently, at four months, the patient transitioned to Nestogen
1 formula, maintaining a consistent weight trajectory. Between four months and six months, the
patient continued with Nestogen 2 formula, again experiencing no notable changes in weight.
From six months onward to the present, the patient has been receiving Bonamil formula,
prepared with six scoops in 180 milliliters of water. Additionally, water intake commenced at six
months of age and has been ongoing since then, although initially administered in small amounts
via drops.
Immunization history
The patient received vaccinations in accordance with the immunization schedule
provided by the local health center. Shortly after birth, the patient received one dose each of the
Bacillus Calmette-Guérin (BCG) and Hepatitis B vaccines, both administered at the local health
center. Subsequently, a series of vaccinations were administered at the same facility, including
three doses of the pentavalent vaccine (Penta) and three doses of the oral polio vaccine (OPV).
Additionally, one dose of the inactivated polio vaccine (IPV) was administered at the local health
center. The patient also received two doses of the pneumococcal conjugate vaccine (PCV) at the
same facility. However, as per the available records, there is no documentation indicating the
administration of the measles, mumps, and rubella (MMR) vaccine to the patient at the local
health center.
Personal and social history
The patient resides in a household where both parents have been together for seven years,
fostering a stable family environment. They live with their parents and an older brother, aged
five, who is currently attending school. The father, aged 23, balances roles as a construction
worker and a student, while the mother, also 23 years old, fulfills responsibilities as a
homemaker and a student as well. Despite their varied roles, both parents actively engage in
their child's upbringing and education. The father serves as the primary provider for the family,
