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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 RR: 42
HR: 102 T: 39 C

CHEST: symmetrical expansion, clear lungs


CVS: normal rate

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