LOPEZ/MANGUILIMOTAN/MENDOZA/NERIDA/PALISTA/PANDUYOS

3/5/2020
General Data:This is the case of Patient G.C, 3 years and 4 mos female, Filipino
Roman Catholic born on and currently residing at Palali, Bantay, Ilocos Sur. During
examination she appears to be active and energetic. She seems to be focused on
watching videos in a cellphone given to her by her mother as a form of entertainment.
Her clothes are clean.
Source and Reliability: Informant is her mother with a reliability of 90%.
Chief Complaint: Difficulty of breathing and rashes
History of Present Illness: An hour prior to admission, the mother noticed the
appearance of rashes on the patient’s face before coughing which was immediately
followed by difficulty of breathing with the patient gasping for air, as described, right
after eating a piece of roasted chicken with gravy from 'Andoks'. These prompted the
parents to bring the child immediately to the hospital with no other symptoms noted,
hence admission.
Past Medical History: The patient is a fully immunized child with no previous
hospital admission and no known food and drug allergies. She was diagnosed with
asthma a week prior to admission. Salbutamol is given as a treatment.
Developmental History: The developmental history of the patient was unremarkable.

Feeding/Nutritional History: The patient eats 3x a day with the usual vegetable
dishes. Breastfed until 2-year old.

Family History: The maternal lineage of the patient has history of asthma. Her nine
year old brother also has an asthma.

Socioeconomic History: The patient lives with her parents together with her older
brother. They live on a for rent house room that share a common kitchen. Her father is
a buko vendor whereas, her mother is a housewife. Water for drinking is bought.

Enviromental History: No cigarette smoker on the family except for their neighbors
(aka: housemates) who constantly smokes outside of the rental house.
Immunization History: Positive fever after administration of the first vaccine.

Review of Systems:
GENERAL: (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness,
(-) body weakness
INTEGUMENTARY: (+) rash, (-) sores, (-) hives, (-) pruritus
HEAD and NECK: (-) headache, (-) trauma, (-) pain, (-) stiffness
EYES: (-) pain, (-) blurring of vision, (-) diplopia, (-) redness, (-) dryness, (-) tearing,
(-) use of corrective lenses
EARS: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
NOSE: (-) smell dysfunction, (-) pain, (-) discharges, (-) sneezing
MOUTH: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice, (-)
decreased gustatory sensation
RESPIRATORY: (+) cough, (-) dyspnea, (-) sputum, (-) hemoptysis, (-) cyanosis, (-)
wheezing, (-) PTB exposure
CARDIAC: (-) chest pains/discomfort, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-)
palpitation, (-) fatigue, (-) edema, (-) syncope, (-) cyanosis, (-) exercise limits
VASCULAR: (-) intermittent claudication, (-) leg cramps
GASTROINTESTINAL: (-) anorexia, (-) nausea/retching, (-) vomiting, (-) dysphagia, (-)
hematemesis, (-) indigestion, (-) heartburn, (-) abdominal pain, (-) change in bowel habits
RENAL AND URINARY: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
MUSCULOSKELETAL: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-)
history of stiffness, (-) history of trauma, (-) limitation of motion
HEMATOLOGICAL: (-) excessive bleeding, (-) easy bruising
ENDOCRINE AND METABOLIC: (-) heat/cold intolerance, (-) weight change, (-)
polydipsia, (-) polyphagia, (-) polyuria
NERVOUS SYSTEM: (-) headache, (-) syncope, (-) seizures, (-) left or right-sided
weakness, (-) sleep disturbance, (-) coordination problem
PSYCHIATRIC/ EMOTIONAL: (-) anxiety, (-) history of loss of control/violence, (-)
nervousness

Physical Examination:
General Survey: The patient is conscious, coherent, ambulatory, and not in cardiopulmonary
distress
Vital Signs: PR: 158 bpm, RR: 38 bpm, Temperature: 36.7 0C
Anthropometric Measurements: Ht:50cm, Wt:14kg, BMI: 55.9 percentile, Hc:37cm
Skin: Petechial rashes localized around the eyes, no pallor, no jaundice or cyanosis. Warm to
touch with good skin turgor.
HEENT:
 Head: No masses, no lesions. No facial asymmetry. No involuntary movement. No
tenderness noted. No bony depression of the skull.
Eyes: Symmetrical with well distributed eyebrows. No lid lag. Palpebral conjunctiva
with anicteric sclera. Extraocular muscles intact.
Ears: Symmetrical ears with no gross deformities, no mass, no lesions, no discharges,
no tenderness.
Nose: Nasal septum is midline. No gross deformities, no discharge. No sinonasal
tenderness.
Mouth: Oral mucosa moist. No lumps, no lesions. No lip lesions. No tonsillar
enlargement.
Neck: No gross deformities. No cervical lymphadenopathies. No thyroid
enlargement. No noted muscular tenderness and spasm. Distended neck veins noted.
Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. Clear breath
sounds.
Heart: No murmurs or abnormal heart sounds.
Abdomen: Protuberant abdomen. Soft, non-tender. Normoactive bowel sounds.
Extremities: No gross deformities. Normal range of motion. No clubbing noted and with
pinkish nail beds. Bounding left brachial artery with good capillary refill. No soft tissue
abrasions on both upper and lower extremities.

Differential Diagnosis:
 Hypersensitivity reaction