SGD 3 Case Protocol
SGD 3 Case Protocol
SGD 3 Case Protocol
DEPARTMENT OF PEDIATRICS
GENERAL DATA:
WGA, 1 year old, male, Roman Catholic, from Sta. Rosa, Laguna was admitted for the
first time on April 5, 2020 at Perpetual Medical Center at 5:00PM.
INFORMANT: Mother
REVIEW OF SYSTEM:
CNS: (-) loss of consciousness
CVS: (-) pertinent findings
GIT: (+) diarrhea
HEMA: (-) bleeding
FAMILY HISTORY:
The father is a market vendor in good health and the mother is a housewife also in good
health. She has 2 other siblings also in good health.
(+) febrile seizure – maternal side
IMMUNIZATION: Given at the Rural Health Unit
(+) BCG - (+) scar Right deltoid (-) Measles
(+) DPT/OPV – 3 doses (-) MMR
(+) Hib – 3 doses (+) Hepatis B – 3 doses
NUTRITIONAL HISTORY:
He still breastfed with complimentary feeding starting at 6 months. At present he is fond
of eating fish and vegetables.
SOCIOENVIRONMENTAL HISTORY:
The patient lives in a congested neighborhood with her grandparents on the paternal side.
Water comes from deep well and not boiled before drinking.
DEVELOPMENTAL HISTORY:
At present he can walk alone, can follow simple command and can play with other
children.
PHYSICAL EXAMINATIONS:
EXTREMITIES: no edema
GUIDE QUESTIONS:
1. Give possible questions you want to ask the informant and other physical examinations
findings that will help you in diagnosing the case.
2. Give the salient features.
3. What is the possible diagnosis?
4. Give at least 3 differential diagnosis and the basis
5. Give the laboratory test that can be requested and the expected results
6. Explain the pathophysiology
7. What will be your plan of management?