??? group 1: rxmen angustia ayes chan co garcia macapinlac tumibay vega
TRANSCRIPT
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???Group 1: RxMen
Angustia ★ Ayes ★ Chan ★ Co Garcia ★ Macapinlac ★Tumibay
★Vega
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O Purpose of the presentationO Impact of illness to the patient and
familyO Coping mechanismO Family dynamicsO Social resources
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General DataO APO 4 mos./MaleO FilipinoO Roman CatholicO Residing in San Miguel, Pasig CityO Informant: Mother, Father, and
Paternal GrandparentsO Reliability: 70%
O Admitted at PCGH on December 3, 2010
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Chief ComplaintO Fever (2 days)
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History of Present Illness
O 3 weeks PTA O intermittent cough, productive of whitish phlegm
O No associated signs and symptoms
O consult at a private clinicO Ambroxol
(unrecalled dosage) No relief
O Amoxicillin 6.75 mg No relief
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History of Present Illness
O 2 weeks PTA O persistence of symptomsO consult at a private clinic
O CarbocisteineO Co-trimoxazole
(unrecalled dosage)O Phenylpropanolamine
(Disudrin) 0.5 ml QID O Phenylephrine HCl,
chlorphenamine (Neozep) 0.5 ml QID
O No relief
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History of Present Illness
O 2 days PTA O persistence of symptoms
O (+) undocumented fever
O (+) Difficulty of breathing
O No consult done O Parents self-
medicated patient with Paracetamol drops 8.45 mg/kg/dose
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History of Present IllnessO Morning PTA O persistence of symptoms
O (+) rhinorrhea, productive of yellowish-green mucous
O (+) vomiting milk and phlegm (about 4 oz)
O Consult at health centerO Cephalexin 32.43
mg/kg/dayO Paracetamol 8.45
mg/kg/doseO Increase in feverO (+) cyanosis of distal
extremitiesPCGH ER
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Review of SystemsO Constitutional: no weight loss, no
weakness O Integument: (+) rashes (diaper), no
changes in colorO Respiratory: no hemoptysisO Gastrointestinal: no changes in
bowel movementO Genitourinary: no frequency
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Past Medical HistoryO no previous hospitalizationO no previous operationsO no history of trauma
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Family Medical HistoryO Liver disease, Tuberculosis -
Maternal sideO Breast cancer - Paternal sideO (-) AsthmaO (-) DMO (-) Hypertension, cardiac disease
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Developmental HistoryO patient is a 4 mo., male
O (+) grasps object placed in handO (+) moves head toward soundO (+) reaches for objects O (+) chewsO (+) roll overO (-) chest up, arm support
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Immunization HistoryO BCG - 1 doseO OPV - 1 doseO Hepa B - 1 doseO No HiB
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Birth HistoryO Born Full Term to a 17 year old
G1P1, delivered via Normal Spontaneous Delivery with birth weight 3.6 kg, at a lying-in clinic, attended by midwife, (-) perinatal/neonatal complications
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Nutritional HistoryO Breast fed for 2 weeks then shifted
to milk formula (8 oz. per feeding x 4 feedings a day)
O No known food allergy
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Genogram (12/30/10)I
II
III
49 43
20 18
4 mos.
21 16 15 14 13 11
4648
24 18
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Personal Social historyO Only ChildO Mother - 18 y/o not employedO Father - 20 y/o
factory workerO Parents not marriedO Families are not on good terms
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Environmental history O Patient does not stay permanently in
one household. He is shuttled from the mother’s household to the father’s household and vice versa
O Lives in a 1 story wooden house near the streets with 2 bedrooms.
O The house is well ventilated and well lighted.
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Environmental history O Their water supply comes from
Manila Waters.
O Drinking water of the patient was previously Wilkins, but now the water comes from a refill station
O Garbage is collected every day.
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Physical ExaminationO General Survey:
O Conscious, alert, in mild respiratory distress, well-nourished
O Vital signs: O HR 165HR 165, RR 38, Temp 40.5Temp 40.5ooCC
O Anthropometrics:O Length 59 cm (<3rd percentile)O weight 7.4 kg (50-85th percentile for age,
>97th percentile for length)O HC 40.5 cm (15th percentile), CC 44.3
cm, AC 46.4 cm
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Physical ExaminationO Skin:
O normal skin color, good turgor (CRT<2 sec), flushed skinO (+) diaper rash, inguinal area extending to buttocks, (-)
lesions, flushed skinO HEENT and neck:
O flat, open anterior fontanel; closed posterior fontanel O Normal hair distribution, (-) masses/depressions O anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm
ERTLO (-) ear deformities, (-) discharge, (+) intact tympanic
membrane, (+) cone of lightO (-) nasal deformities, (+) rhinorrhea, yellow-green
discharge slightly driedO (-) Tonsillopharyngeal congestion, (-) cervical
lymphadenopathy, supple neck, flat neck veins
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Physical ExaminationO Heart:
O adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm
O (-) murmurs, good S1/S2O Lungs:
O (-) scars or masses, (+) intercostal/subcostal retractions
O symmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields
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Physical ExaminationO Abdomen:
O globular abdomen, (-) masses or scarsO Normoactive bowel soundsO tympanitic abdomenO (-) tenderness, (-) organomegaly
O Genital exam:O grossly male, (-) deformitiesO Descended testes
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Physical ExaminationO Extremities:
O full and equal pulses, (-) edema, (-) cyanosis
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Neurologic ExaminationO Cranial Nerves:
O CN I - not testedO CN II – 3-4 mm equally reactive to lightO CN III, IV, VI – intact EOMsO CN V – reacts to facial sensory stimulationO CN VII – no facial asymmetry, able to
smile and cryO CN VIII – responds to sound and verbal
stimuliO CN IX, X – able to feed, good suckO CN XI – able to turn head from side to sideO CN XII – tongue midline
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Neurologic ExaminationO Sensory: responds to stimuli (light
touch)O Motor: good muscle tone and strength O Reflexes
O (+) BabinskiO (+) palmar graspO (-) rooting O (-) moroO (-) tonic neck
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Salient FeaturesO 4 mo./M O fever (2 days) associated with cough
and colds, difficulty of breathing, peripheral cyanosis, and vomiting
O medications given afforded no reliefO on PE, (+) tachycardia, (+) intercostal
retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields
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Admitting DiagnosisO Pediatric Community Acquired
Pneumonia, Category CO (+) fever, difficulty of breathing,
cyanosis, cough and coldsO PLUS findings on PE: (+) tachycardia,
(+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles