You are on page 1of 2
YEAR 2014 General Data: This is a case of GK, 7 year old male, Catholic, Filipino, born on September 3, 2014, presently residing at De la Paz, Bifian Laguna, admitted for the 1" time in this institution Chief Complaint: joint pains and inability to walk HISTORY OF PRESENT ILLNESS: 5 weeks prior to consultation, the patient was noted to have undocumented fever and throat pain with difficulty of swallowing. Self-medicated with Paracetamol syrup and Amoxicilin for 4 days which afforded relief of the symptoms. No consultation was done. 7 week prior to admission, the patient complained of undocumented fever, with right knee pain (pain score of 5/10) migrating to the left ankle and left shoulder, easy fatigabilty and ‘occasional chest pain. Patient was given Paracetamol at 10 mag/kgidose which afforded temporary relief of the joint pain only to recur 2 days PTA this time with inability of walk and dyspnea Persistence of the said symptoms prompted consult, hence admitted REVIEW OF SYSTEMS: General: (+) loss of appetite, (-) chills, (-) weight loss CNS: () seizure HEENT: frequent upper respiratory tract infection Respiratory: (-) cough Cardiovascular: (-) palpitations Gastrointestinal (-) loose bowel, (-) voriting (-) abdominal pain, regular bowel movernent GenitoUrinary: (-) hematuria Musculoskeletal: (+) restriction of movement Hematologic: (-) easy brusabilty (-) pallor Integumentary: (-) pigmentation Neurologic exam: loss of conscious while playing basketball Maternal History: Patient was born to a 32 year old G3P2 (2002) mother with regular prenatal check up land regular intake of multivitamins, No history of maternal infection, No exposure to radiation or any teratogenic substance. Birth History: Patient was born term, live baby boy, delivered via NSD, in a lying in. No cord coiling or meconium staining upon birth with spontaneous respiration and good cry. Birth weight was unrecalled. Neonatal History No jaundice nor cyanosis or other complications. Patient was able to pass meconium and urine within 24 hours of life. Newborn screening was done and revealed normal result Nutritional History: Patient was breastfeed until 1 year old and was shifted to formula milk with unrecalled dilution, Time of weaning was unknown. At present, patient's diet consists of rice, meat, fruits and vegetables. Growth and Development: ‘At present, the patient is a grade 1 student who performs well in school. Immunization history: Patient had BOG (right deltoid) and influenza vaccine in 2010. Other vaccines were unrecalled, Past Medical History: Recurrent history of Acute Tonsillopharyngttis, ocourring 3x in a year Family History: First cousin has rheumatic heart disease and a sibling has congenttal heart disease Personal and Social History: Patient is in Grade 1 and active in class. Parents are both working. Lives in a bungalow located in a low cost housing project of the government in a semi congested neighbourhood. Garbage is being disposed on a weekly basis. PHYSICAL EXAM: Gen Survey: conscious, coherent, not in Cardiorespiratory distress VS: BP = 90/60 mm Hg CR=90bpm T=38.5C RR=24opm AM: BW= 20kg Height: 115 om BMI: 15.1 Skin: warm, soft, with good skin turgor, no rashes HEENT: Pink palpebral conjunetivae, anicteric sclerae, no aural nor nasal discharge, no cervical lymphadenopathy, supple neck IL: equal chest expansion no ICS and subcostal retraction, equal tactile and vocal fremitus resonant on percussion, good air entry, clear breath sounds Heart: dynamic precordium, PMI at 6" ICS LMCL, positive heave at the apex, no tap, positive systolic thrill at apex, Grade 5/6 pansystolic murmur best heard at the apex, grade 4/6 diastolic murmur at the right upper sternal border, grade 5/6 diastolic murmur at the right upper sternal border, grade 3/6 systolic ejection murmur right upper sternal border radiating to the neck ‘Abdomen: flat, normal bowel sounds liver span 8 om. Extremities: posttive tendemess of the ankle and knee joints, bounding pulses, CRT less than 2 seconds Neurologic Exam: Normal GUIDE QUESTIONS: Please give a critic of the history and physical exam of the patient. Enumerate the salient features of the patient. What are the differential diagnosis and basis? What is your impression and basis? Enumerate the lab exams to support the diagnosis ‘Treatment plan (short and long term) pian including bed rest Study the pathogenesis and correlate the clinical symptoms of the patient NoOgsena

You might also like