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RTRMF College of Medicine, S.Y.

2017-18
Department of Pediatrics
Student: Pumanes, Eleanor Eden J.
Preceptor: Dr. Agosto
Date: August 3,2017

Date and Time of Interview: July 13, 2017 at 10:45 a.m.


Source(s) of Information: Mother
Reliability: 90%
Source(s) of Referral: None

I. IDENTIFYING DATA
J.C, a 2 year-old boy, born on December 9, 2014, currently living in Brgy.
Salvacion, Palo, Leyte, Roman Catholicwas admitted for the first time at Eastern
Visayas Regional Medical Center (EVRMC) on June 27, 2017 at around 10:00 p.m.

II. CHIEF COMPLAINT


Convulsion

III. HISTORY OF PRESENT ILLNESS

The patient is apparently well until4 days prior to admission, 11:00 am, when he developed
a mild fever. Mother wasn’t able to get the specific temperature of the patient but described it
slightly hot upon touch. There was no colds, no headache and no cough. No consultation was done
nor medication given, only a sponge bath done by his mother. His fever worsened so his mother
gave him Paracetamol (Tempra) 80 mg/5ml, 5ml, single dose (AD 16 mkd) given at 5:00 p.m.
from which he was slightly relieved. This was not followed by additional doses.
Three days prior to admission, patient’s fever worsened again but no medication was given.
His mother only gave him a sponge bath and this persisted until the following day. Still, no colds
nor cough and no dyspnea.
On the day of admission, June 27,2017 2:00 p.m., patient’s fever persisted which caused
him to have a convulsion of 1 minute duration. Mother said his body was stiffening, eyes directed
upward, and patient became cyanotic. Excessive salivation follows every convulsion. No cough,
no colds, no abdominal pain and no vomiting. Still, no medical consultation was done and no
medication was given aside from mother’s usual sponge baths. At 5:00 p.m., the patient convulsed
again, now of about 2-minute duration so his mother gave him Paracetamol (Tempra) 80 mg/5ml,
5ml, single dose (AD 16 mkd)but did not give him any relief. His fever still persisted and
convulsion occurred again at 7:00 p.m. still of 2-minute duration but now, patient is dyspnic. No
medical intervention was done until another convulsion occurred at 10:00 p.m which prompted the
mother to seek for consultation, hence, admission.

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IV. PERSONAL HISTORY
A. Prenatal History
The patient was born to a 31 year-old G1 P1 (1-0-0-1) mother who did not smoke
but drinks tuba at least 10 glasses per session with her husband due to certain
occasions. The prenatal check-up was done at Schistosomiasis Hospital conducted
by a nurse. The first prenatal check-up was at 1 month AOG, and done monthly
until the 9th month AOG. The mother received her first Tetanus Toxoid vaccine
on the 2nd trimester of pregnancy, but did not take Ferrous Sulfate nor Folic Acid
because mother claims that she did not like the taste. She had a fever,cough and
colds during her 4th month AOG which lasted for 3 days from which she self-
medicated with Biogesic once a day. There was no history of hypogastric pain,
persistent uterine contractions, vaginal spotting, and watery vaginal discharges as
well as radiation exposure.

B. Birth History
The patient was delivered full term via NSVD assisted by a midwife in
Schistosomiasis Hospital. He was delivered in cephalic presentation after one hour
of active labor. He was born first followed by his twin sister. There were no
abnormalities observed such as erythema, jaundice, head molding or respiratory
distresss.

C. Neonatal History
The patient was pinkish with a loud cry approximately 5 minutes from birth and
with vigorous movement as described by the mother. There were no associated
fever, convulsions, and bleeding. The first stools (Meconium) was passed out after
10 hours of life characterized as green, jelly-like, and odorless. The first urine was
passed out an hour after. There was no complication observed at the umbilical area
such as hernia or hematoma.

D. Feeding Pattern
The patient was breastfed 5 hrs after birth when he already came inside the hospital
room of his mother then it was followed by short periods upon crying. His mother
claimed to have difficulty of breastfeeding the patient for long period of time
because she also have the other twin to attend to. Patient’s breastfeeding was mixed
with bottle feeding at 5 months. Supplemental feeding or solid food was introduced
at 1 year of age consisting of cerelac. Vitamins were not given.

24-Hour Diet Recall

Before Onset of Illness

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Time Food Proportions Calories
Breakfast Biscuit (6 pc 1 piece x 86 cal = 153 cal 86 cal
Snack none
Lunch Steamed rice 1/2 cup: 0.5 x 204 cal (per cup) 102 cal
= 102 cal
Fried fish 1 piece: 3 matchboxes: 1 x 251 251 cal
cal
Snack none
Dinner Steamed rice 1 cup: 1 x 204 cal (per cup) = 204 cal
204 cal
Fried fish 1 piece: 3 matchboxes: 1 x 251 251 cal
cal
TOTAL 894 cal

V. GROWTH AND DEVELOPMENT


Gross Motor Adaptive Fine Motor
- Hand fisted at 1 month - Grasps Object placed in hand at 4 months

- Good head control at 2 months - Holds bottle at 9 months

- Sits without support at 8 months - Thumb finger grasp at 10 months


- Stands alone at 12 months - Drinks from cup at 15 months

- Runs well at 2 years - Imitates a circular stroke at 2 years


- Jumps at 2 ½ years - Imitates a circle at 2 ½ years

Language Personal Social


- Moves head towards sound at 4 months - Smiles at 1 month
- Imitates sound at 9 months - Plays peek-a-boo
&close-open
hand movement
- Obeys command or requests at 12 months - Uses spoon At 18 months
& says one word other
than “Mama/Dada”
- Combines 2/3 words at 2 years - Remove garment at 2 years
in sentences & & toilet trained
points to 1 body parts by day
- Follows 2/3 directions at 2 ½ years - Uses spoon with at 2 ½ years
and names 1 picture little spillage

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VI. BEHAVIOR
The patient is playful but irritable at times. Sleeping habits wakes up at 8 a.m. and
sleeps at 9 p.m. He started thumb sucking at 1 year-old and ended when he turned 2
years old.

VII. IMMUNIZATION
Completely immunized.

Name of Vaccine Age Given Adverse


Reactions
BCG 1 month None
DPT 1 1 1/2 months None
DPT 2 3 months None
DPT 3 4 months None
OPV 1 2 months None
OPV 2 4 months None
OPV 3 6 months None
HBV 1 1 month None
HBV 2 4 months None
HBV 3 6 months None
Measles Vaccine 9 months Fever

VIII. PAST MEDICAL HISTORY

Childhood illnesses: No history of mumps, chicken pox, tonsillitis, chicken pox,


gastroenteritis, measles, and typhoid fever.
Previous Hospitalization: None
Previous Surgeries: None
Allergies: No allergies to food and drugs
Past Blood Transfusions: None
Accidents/Injuries: None
Past illnesses: Occasional cough and colds but the mother can not
remember the specific dates

IX. FAMILY HISTORY


Patient’s father, aged 30 years old, works as a pedicab driver. On the other hand, his
mother, aged 31 years old, is a housewife. The patient also have a twin sister. Parents
and his twin sister are apparently well.

There is history of hypertension and mental illness in the family, but no history of
diabetes, thyroid disease, kidney disease, heart disease, and cancer.

X. PSYCHOSOCIAL HISTORY

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The patient’s parents live in Brgy. Salvacion, Palo, Leyte within a 1-storey well-
ventilated wooden house situated along the river. Their house has a functional water-
sealed toilet. The patient’s mother does not smoke, but her father is a cigarette smoker
and both parents are occasional alcoholic drinker. The mother disclosed disposal of
garbage including plastics in a pit and sometimes thru burning. There are rats,
cockroaches, insects especially mosquitoes at home. They obtain drinking water from
their faucet and get water from the nearby water-pump for household use. Their daily
food varies from vegetables and fish.

XI. REVIEW OF SYSTEMS


General: no weight loss and no malaise. Had fever.
Skin: No itchiness, no sores, no lesions, no rashes and no lumps.
HEENT
Head: No headache, dizziness, and light-headedness.
Eyes: No pain, no redness and no excessive tearing
Ears: No pain, or abnormal discharges.
Nose: No nasal stuffiness, no nasal discharges, no itching and no epistaxis, with colds.
Mouth/Throat: No difficulty swallowing, no sore throat and no bleeding gums
Neck: No lumps, no pain, and no nuchal rigidity
Respiratory: Has a productive cough of white sputum, no dyspnea, no hemoptysis,
Cardiovascular: No chest pain, no palpitations and no cyanosis.
Gastrointestinal: no vomiting,no diarrhea,no constipation, and no excessive
belching. Defecates once a day of brown and formed stool.
Peripheral Vascular: No edema on both legs. No leg cramps.
Urinary: No dysuria. No polyuria, no hematuria. No oliguria. No flank pain.
Frequency
of urination: 4-5 times a day (250 ml per urination).
Genitals: No discharges nor sores. No itchiness.
Musculoskeletal: No muscle pains, no joint paints, and no weakness.
Neurologic: Had convulsion, no loss of consciousness, no involuntary movements
Hematologic: No easy bruising and no easy bleeding.
Endocrine: No heat or cold intolerance and no excessive thirst and hunger.
Psyatric: No nervousness, no tension and no tantrums.

XII. PHYSICAL EXAMINATION


A. General Survey
The patient was examined ambulatory, conscious and coherent. He is playful but
gets irritable at times. He was alert and oriented to person and place. He appears
well-nourished and not in cardiopulmonary distress. He is afebrile, with the
following vital signs and anthropometric measurements:

Vital signs:
Vital Signs Actual Measurement Normal Value/Range

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Temperature 35.9 C (R axilla) 36.2 – 37.2 °C
Blood Pressure (BP) Not performed 80-110/50-80 mmHg
Pulse Rate (PR) 92 bpm 75-115 bpm
Respiratory Rate (RR) 24 cpm 20-30 cpm

Actual
Anthropometric measurements: Z-score Percentile Rank
Measurement
Weight 13 kg 0 Above 30th
(Median) percentile
Height 84 cm -2 <2nd percentile
Head Circumference (HC) 49 cm 0 50th percentile
(Median)
Mid-Upper Arm Circumference 15 cm - -
(MUAC)
Chest Circumference (CC) 54 cm ̶ ̶

Wasting: (Actual Wt. / ideal Wt. for actual Ht/Length) x 100 Normal > 90%
Mild 80-90%
(13/13.2) x 100 =98.5 Normal Mod 70-80%
Severe < 70%

Stunting: (Actual Length/Ht. / ideal Length/Ht. for age) x 100 Normal > 95%
Mild 90 -95%
(84/92) x 100 = 91.3 Normal Mod 80 -90%
Severe < 80%

B. Integument
The skin was warm to touch and brown in complexion. There were no
rashes, petechiae, active lesions, hypo- or hyperpigmentation, cyanosis, and edema.
C. Head
The head was normocephalic and atraumatic. The patient had short, black fine hairs.
No lumps, no tenderness and no scars on the scalp.
D. Eyes
Eyebrows were symmetrical, fine, black and there was no scars or active lesions.
Eyelashes were fine and directed outwards. No edema, no ptosis and no lid lag.
Conjunctiva was pinkish and sclera was anicteric. There were no ulcerations, no
scars and no opacities of the cornea. Pupils were symmetrical and reactive to direct
and consensual light stimulation. There was full extra ocular movements.

E. Ears
Symmetrical in alignment and shape. Firm pinnae. No pain and abnormal
discharges. No active lesions and impacted cerumen. Acuity intact.

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F. Nose
No nasal flaring and abnormal discharges. No septal deviation, no itching nor
redness and no epistaxis.
G. Mouth and Throat
The lips, mucous membranes, and tongue were moist and pinkish without bleeding
and lesions. The gums were pinkish. There was no cleft palate and cleft lip and no
tongue tie. Complete set of teeth and there were no dental carries. Tongue was
pinkish, no ulceration, no papillary atrophy and no tremors upon protrusion.Uvula
at midline.
H. Neck
Thyroid gland not palpable and moves with deglutition. The neck was supple. The
trachea was at the midline. No enlarged lymph nodes. No engorged veins and
visible pulsations.
I. Breasts
Breasts were symmetrical. No lumps and abnormal discharges.
J. Chest and Lungs
Inspection: Truncal in shape. No subcostal or intercostal retractions. No lesions
and lumps.
Palpation: Not performed.
Percussion: Not performed.
Auscultation: No adventitious breath sounds. Vesicular breath sounds in all lung
fields.
K. Heart
Inspection: No precordial bulging, no visible pulsations, and no lumps
Palpation: Apex beat palpable at 5th left ICS at MCL. No thrills and heaves.
Percussion: Not performed.
Auscultation: First and second heart sounds were clear and well-defined. No
murmurs, bruits, and precordial friction rub.

L. Abdomen
Inspection: The abdomen was full, and non-distended. No visible peristalsis,
engorged veins, and hyper and hypopigmentation. No bulging and
inverted umbilicus..
Palpation: Soft, and non-tender. Liver, spleen, and kidneys not palpable. No
masses
Percussion: Not performed.
Auscultation: The bowel sounds were normo-active, with 10 bowel sounds per
minute. No arterial bruitand venous hums.
M. Extremities
Symmetrical in length. There are no deformities, lesions, edema, cyanosis, and
atrophy. There are no muscular tenderness.

N. Back and Spine

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There are no abnormal deviations. No retraction, bulging, and paravertebral
tenderness or mass.
O. Genitalia
No lesions in the penis and no abnormal discharge.

XIII. NEUROLOGIC EXAM


A. Mental status exam: Patient is awake and attentive.
B. Cerebellum: Not tested.
C. Cranial Nerves:
CN I – Not tested.
CN II – Pupils are 2 mm in diameter, equally round and reactive to light and
accommodation.
CN III, IV, and VI – The patient was able to move eyes upward, downward,
medially, laterally.
CN V – Not tested.
CN VII – Face is symmetric with normal eye closure.
CN VIII –Responsive to verbal stimuli.
CN IX and X – Not tested.
CN XI –Able to turn head to both sides against resistance
CN XII–The tongue is at midline upon protrusion
D. Motor: Not tested.
E. Sensory:Not tested.
F. Reflexes:
a. Primitive Reflexes: Absent primitive reflexes.
b. Superficial Reflexes: Not performed
c. Deep Tendon Reflexes:

d. Pathologic Reflexes: (+ ) Babinski; (-) Clonus

G. Meningeal: No nuchal rigidity


Kernig’s sign and Brudzinski’s sign not performed

H. Autonomics: No excessive sweating.