PEDIATRIC SAMPLE DATADASE/CASE
PATIENT DATA
Name: M.J.
Age: 12 yo/M
Birthday: 4/20/2011
Source: Patient’s father
Reliability:95%
Chief Complaint: Fever
9 days PTA, the patient presented with the onset of difficulty and painful urination, no hematuria
associated; patient also had a productive cough characterized by greenish sputum, accompanied
by a lip lesion on the left side. The patient did not initiate any medication and did not seek
medical consultation.
6 days PTA, the patient continued to experience a productive cough, still with difficulty and pain
during urination, now coupled with an unrecorded fever. The patient self-administered solmux
capsules thrice daily and paracetamol 500mg tablets thrice daily, resulting in transient relief.
5 days PTA, the patient's symptoms persisted, with the cough remaining productive and the
fever accompanied by vomiting on four occasions, with each episode expelling approximately
half a cup of previously consumed food.
During the interim period, the patient's symptoms of productive cough and fever persisted, and
treatment with solmux capsules and paracetamol 500mg tablets provided temporary alleviation.
1 day PTA, the patient's condition deteriorated, marked by an elevated fever reaching a
maximum of 39.1°C and the appearance of pustular skin lesions, initially localized to the neck
and subsequently spreading to the upper extremities and back. Seeking medical attention, the
patient consulted a private physician, who recommended further investigation. Subsequent
workup revealed leukocytosis and pyuria. The patient was prescribed Co-amoxiclav and
Azithromycin and was referred to a pediatrician.
Upon consultation with a private pediatrician on the day of admission, the patient's laboratory
results were reviewed, revealing hypotension (80/40 mmHg) and the presence of skin lesions.
Consequently, admission and transfer to our institution were advised for comprehensive
management, leading to the current admission.
Past Medical History
The patient has no known history of childhood diseases. However, there is a positive
history of learning and speech disability diagnosed in 2021, which may require further attention.
The patient does not have a history of hypertension, diabetes mellitus, or bronchial asthma.
There is also no history of tuberculosis or exposure to tuberculosis. The patient has not been
,previously admitted to a hospital nor undergone any surgeries. Furthermore, there are no known
food or drug allergies reported for the patient.
Antibiotic History:
Co-amoxiclav 500mg/tab, 1 tab BID for 7 days x 2 doses (last dose 7am 03/20), Azithromycin
500mg/tab, 1 tab OD for 3 days x 1 dose (last dose 7pm, 03/19)
Family History:
In terms of family medical history, the patient's mother has a history of hypertension but
does not have diabetes mellitus, bronchial asthma, cancers, or heart disease. On the paternal
side, the patient's father also has hypertension and is free from diabetes mellitus and bronchial
asthma. However, there is a positive history of cancers, specifically colon cancer and bladder
cancer. Heart disease is not present in the paternal medical history.
Prenatal history:
During the prenatal period, the patient’s mother attended eight obstetric check-ups.
They adhered to a routine intake of supplements, including folic acid, ferrous sulfate, calcium,
and multivitamins, each taken once daily. No complications arose during the pregnancy, and the
patient’s mother abstained from smoking and consuming alcoholic beverages. There is no history
of previous COVID-19 infections, and the patient has been vaccinated against non-COVID-19
pathogens.
Birth history
Delivered term to a 33 yo G1P1 mother via NSVD at a private hospital
Neonatal history
The patient experienced neonatal complications, requiring a one-week admission to the
Neonatal Intensive Care Unit (NICU) due to meconium aspiration. However, there were no
reported feeding issues following birth, and no newborn screening or hearing screening tests
were conducted.
Developmental history
Gross Motor: Able to walk at 12 months
Fine Motor: Able to read and write at 9 years old
Language: Able to communicate with parents and friends, able to reason and express his feelings
however as claimed by patient’s father, patient undergo speech therapy last 2019 (8 months)
Personal Social: Able to socialize with family and friends, denies bullying
Patient started to go to school at 6 years old
, Feeding history
Patient was breastfed for 1 week then formula milk until 3 years old
Diet: Rice, vegetables, fruits, fish, and meats
Water intake: <1L
Immunization history
1x BCG at birth - Private Hosp
1x Hep B at birth - Private Hosp
3x Penta - Private Hosp
3x OPV - Private Hosp
1x IPV - Private Hosp
3x PCV - Private Hosp
1x Measles - Private Hosp
1x MMR - Private Hosp
No Rotavirus vaccine
No varicella vaccine
No Japanese Encephalitis
Personal and social history
The patient's parents have been together for 15 years, and the patient resides with them
along with two siblings. The patient's mother serves as the primary provider, while the father
assumes the role of primary caregiver. The patient themselves is a nonsmoker, does not
consume alcohol, and denies any use of illicit drugs.
Environmental history
The patient resides in a rented single-story house constructed of cemented materials,
which boasts good ventilation. However, they are exposed to secondhand smoke, primarily from
their father. The household's water source is a water refilling station. Additionally, the patient is
exposed to potential infectious diseases within their household and neighborhood. The patient's
father has experienced fever and cough for five days without seeking medical consultation.
PATIENT DATA
Name: M.J.
Age: 12 yo/M
Birthday: 4/20/2011
Source: Patient’s father
Reliability:95%
Chief Complaint: Fever
9 days PTA, the patient presented with the onset of difficulty and painful urination, no hematuria
associated; patient also had a productive cough characterized by greenish sputum, accompanied
by a lip lesion on the left side. The patient did not initiate any medication and did not seek
medical consultation.
6 days PTA, the patient continued to experience a productive cough, still with difficulty and pain
during urination, now coupled with an unrecorded fever. The patient self-administered solmux
capsules thrice daily and paracetamol 500mg tablets thrice daily, resulting in transient relief.
5 days PTA, the patient's symptoms persisted, with the cough remaining productive and the
fever accompanied by vomiting on four occasions, with each episode expelling approximately
half a cup of previously consumed food.
During the interim period, the patient's symptoms of productive cough and fever persisted, and
treatment with solmux capsules and paracetamol 500mg tablets provided temporary alleviation.
1 day PTA, the patient's condition deteriorated, marked by an elevated fever reaching a
maximum of 39.1°C and the appearance of pustular skin lesions, initially localized to the neck
and subsequently spreading to the upper extremities and back. Seeking medical attention, the
patient consulted a private physician, who recommended further investigation. Subsequent
workup revealed leukocytosis and pyuria. The patient was prescribed Co-amoxiclav and
Azithromycin and was referred to a pediatrician.
Upon consultation with a private pediatrician on the day of admission, the patient's laboratory
results were reviewed, revealing hypotension (80/40 mmHg) and the presence of skin lesions.
Consequently, admission and transfer to our institution were advised for comprehensive
management, leading to the current admission.
Past Medical History
The patient has no known history of childhood diseases. However, there is a positive
history of learning and speech disability diagnosed in 2021, which may require further attention.
The patient does not have a history of hypertension, diabetes mellitus, or bronchial asthma.
There is also no history of tuberculosis or exposure to tuberculosis. The patient has not been
,previously admitted to a hospital nor undergone any surgeries. Furthermore, there are no known
food or drug allergies reported for the patient.
Antibiotic History:
Co-amoxiclav 500mg/tab, 1 tab BID for 7 days x 2 doses (last dose 7am 03/20), Azithromycin
500mg/tab, 1 tab OD for 3 days x 1 dose (last dose 7pm, 03/19)
Family History:
In terms of family medical history, the patient's mother has a history of hypertension but
does not have diabetes mellitus, bronchial asthma, cancers, or heart disease. On the paternal
side, the patient's father also has hypertension and is free from diabetes mellitus and bronchial
asthma. However, there is a positive history of cancers, specifically colon cancer and bladder
cancer. Heart disease is not present in the paternal medical history.
Prenatal history:
During the prenatal period, the patient’s mother attended eight obstetric check-ups.
They adhered to a routine intake of supplements, including folic acid, ferrous sulfate, calcium,
and multivitamins, each taken once daily. No complications arose during the pregnancy, and the
patient’s mother abstained from smoking and consuming alcoholic beverages. There is no history
of previous COVID-19 infections, and the patient has been vaccinated against non-COVID-19
pathogens.
Birth history
Delivered term to a 33 yo G1P1 mother via NSVD at a private hospital
Neonatal history
The patient experienced neonatal complications, requiring a one-week admission to the
Neonatal Intensive Care Unit (NICU) due to meconium aspiration. However, there were no
reported feeding issues following birth, and no newborn screening or hearing screening tests
were conducted.
Developmental history
Gross Motor: Able to walk at 12 months
Fine Motor: Able to read and write at 9 years old
Language: Able to communicate with parents and friends, able to reason and express his feelings
however as claimed by patient’s father, patient undergo speech therapy last 2019 (8 months)
Personal Social: Able to socialize with family and friends, denies bullying
Patient started to go to school at 6 years old
, Feeding history
Patient was breastfed for 1 week then formula milk until 3 years old
Diet: Rice, vegetables, fruits, fish, and meats
Water intake: <1L
Immunization history
1x BCG at birth - Private Hosp
1x Hep B at birth - Private Hosp
3x Penta - Private Hosp
3x OPV - Private Hosp
1x IPV - Private Hosp
3x PCV - Private Hosp
1x Measles - Private Hosp
1x MMR - Private Hosp
No Rotavirus vaccine
No varicella vaccine
No Japanese Encephalitis
Personal and social history
The patient's parents have been together for 15 years, and the patient resides with them
along with two siblings. The patient's mother serves as the primary provider, while the father
assumes the role of primary caregiver. The patient themselves is a nonsmoker, does not
consume alcohol, and denies any use of illicit drugs.
Environmental history
The patient resides in a rented single-story house constructed of cemented materials,
which boasts good ventilation. However, they are exposed to secondhand smoke, primarily from
their father. The household's water source is a water refilling station. Additionally, the patient is
exposed to potential infectious diseases within their household and neighborhood. The patient's
father has experienced fever and cough for five days without seeking medical consultation.
