PATIENT’S PROFILE Date: July 20, 2009 Time: 1:40 pm Name: DE CHAVEZ, BRYNTH IAN LUMIBAO Age: 2 mos. old Birthdate: May 10, 2009 Address: Pilar, Sorsogon Sex: Male Religion: Roman Catholic Citizenship: Filipino Mother: Alija Aiza De Chavez Father: Clinical Record Admitting diagnosis: Hirschsprung’s disease with acute colitis Admitting Physician: Dr. Ma. Teresa Bose Chief Complaint: Diarrhea Brief History: 3 days prior to consultation, patient had experiences watery stools 4 times 1 day prior to consultation, patient had continuous watery stools and experienced fever Admitting vital signs: Wt: 4.1 kg HR: 102
RR: 42 T: 39 C
CHEST: symmetrical expansion, clear lungs CVS: normal rate