University of Northern Philippines

College of Medicine

PHYSICAL DIAGNOSIS II A

GROUP 1

SUBMITTED TO:

DRA. IRWINA LAZO

SUBMITTED BY:

Abalos, Mary Abigail

Ajos, Joanne

Alon, Aldrin Jan

Alug, Ivy Nikki Marie

Alviar, Neil

26 March 2018
Date and time of the Interview: 21 March 2018, 3:00 PM

General Data
T.D. 4 months old, male, Filipino, born on November 1, 2017 at Gabriela Silang,
Hospital, Tamag, Vigan City, Ilocos Sur, Roman Catholic, a resident of Sto. Domingo, Ilocos
Sur.

Informant: Mother

% Reliability: 90%

Chief Complaint: “napartakpanagangesna” (rapid breathing)

History of Present Illness

Three days PTA, the patient experienced nonproductive cough precipitated by active
playing, which is more prominent at night. Clinic consult was done and medications given were
Cefaclor (3x a day), Cetirizine (once a day) and Salbutamol nebulization (3x a day) which
afforded temporary relief. No associated fever, colds, and vomiting were noted.
Two days PTA, cough still persisted with the same characteristics, no fever but with
associated colds with white nasal discharge. Same medications were given which provided
transient relief.
A day PTA, cough and colds still persisted with the same characteristic, intensity and
frequency, still aggravated by active playing; patient was continued on the same medications
with resultant transient relief. No other associated signs and symptoms like fever and vomiting.
Thirty minutes PTA, recurrence of cough and colds was noted precipitated by active
playing but this time, associated with persistent rapid breathing, without fever; same medications
were given but afforded no relief thus prompting his admission to Gabriela Silang Hospital.

Gestational History
T.D. was born to a G1P1 (1001) 25 y/o mother, cognizant of an unplanned pregnancy at 1
month AOG through pregnancy test. Prenatal check-up was done on a regular basis (monthly)
starting at 1 month AOG; ultrasound was done on the 7 th and 9th month AOG; diet was composed
of rice, vegetables, meat and fish. Two doses of TT vaccine were given at the 6 th and 7th month
AOG. Mother took Ferrous Sulfate and Folic Acid during the entire duration of pregnancy;
experienced UTI during her 2nd trimester and took antibiotic for 1 week; claimed to have cough
and fever during her pregnancy. No history of exposure to radiation and intake of teratogenic
drugs; denies any alcohol and substance abuse.
Natal History
Patient was born term via forceps delivery in a cephalic presentation, meconium stained
after prolonged labor. Birth weight and length are 2.5 kg and 49 cm respectively.

Neonatal History
Patient was noted to have apnea, absence of cry and no active movement; immediate
resuscitative measure was done; patient was brought to the NICU for management; underwent
antibiotic therapy; was on CPAP; and was discharged after 10 days. No congenital abnormalities
and injuries at birth.

Feeding History
Exclusive breastfed on the 1st 2 months and started mixed feeding (breast milk and
formula milk) at 3 months with the same duration (1 hour), 6-7 times a day.

Developmental History
At 1st week of life, patient was able to lie in flexed position, turned head side to side, head
lagged on ventral suspension, fixate face on light in line of vision and exhibited visual preference
for human face.
At 1 month, patient’s head lagged when pulled to sit and followed objects to midline.
At 2 months, patient was able to smile and coos socially, follow objects past midline, and
the head lagged on pull to sit.
At 3 months, patient was able to visually tracked objects well, had a good head control on
prone position and looked around, had improved head control on sitting position and sustained
smiling and cooing.
At 4 months, patient began to reach for toys symmetrically; able to regard toys and put
them into mouth; had good head control on sitting position; able to play with hands and laugh.

Past Illness
No known history of contagious diseases such as measles, varicella mumps, and
pneumonia. No known episodes of asthmatic attack.

Immunization History
The patient received one dose of BCG and 1st dose of Hepatitis B vaccine at birth.
Received 3 doses of Pentavalent (pentahib) and 3 Polio vaccine both at 6th, 10 th and 14th week of
life, respectively.
Family History
Father is 23 y/o, mason, smoker and drinks alcoholic beverages, apparently healthy.
Mother is 25 y/o, housewife, does not drink alcoholic beverages, diagnosed to be asthmatic. The
patient is the 1st child of a non-consanguineous union. Paternal grandfather is diabetic and
maternal grandmother is asthmatic. Denies heredofamilial diseases like cancer, epilepsy, allergy,
hereditary haematological disorders, mental retardation, and congenital defects.

Socio-economic History
Family is composed of eight household members, living in a bungalow-type house, well
lit and well ventilated with bedrooms and one comfort room. Drinking water is from the water
refilling station. Income comes from the remuneration of the father as a mason.

Environmental History
House is located near the highway and school with no nearby factories; family owns a pet
dog. Household wastes are collected by garbage haulers.

Review of Systems (ROS):

General: (-) fever
Cutaneous: (-) Rashes, (-) Dryness, (-) Lumps, (-) Sores, (-) change in color
Head: (-) Head injury
Eyes: (-) Redness, (-) icteric sclera
Ears: (-) Discharge
Nose and Sinuses: (+) colds,(+) Nasal Discharge
Mouth and Pharynx: (-) Bleeding gums, (-) Sore tongue
Neck: (-) Lumps, (-) Swollen glands
Cardiovascular: (-) Cyanosis
Respiratory: (+) Cough, (-) Difficulty of breathing, (+) rapid breathing
Gastrointestinal: (-) Diarrhea
Genitourinary: (-) hernia, (-) lumps
Nervous/ Behavioral: (-) Convulsions, (-) Seizures
Musculoskeletal: (-) Swelling in joint or muscle, (-) Limitation of motion
Hematopoietic: (-) Pallor, (-) Bleeding manifestations, (-) Easy bruisability

Physical Examination
General Survey
The patient is awake, reacts to stimuli, actively moves but irritable, with a loud cry and
noted to have head bobbing.
Vital Signs
Axillary temperature of 35.9 degrees C, respiratory rate of 64 bpm, and cardiac rate of
105 bpm. Blood Pressure was not taken.

Anthropometric Measurement
Weight of 6 kg, length of 24 in, head circumference of 41 cm, chest circumference of 44
cm, and abdominal circumference of 45 cm.

Skin
Skin is dry, cold to touch and pinkish. No rashes and lesions noted.

Head, Eyes, Ears, Nose, Throat (HEENT)

Head: Normocephalic, no deformities of scalp, and evenly distributed black hair. Palpable
anterior fontanels.
Eyes: Sclerae is anecteric, pink conjucntiva, and no conjunctivitis. No periorbital edema, and
pupil is equally round, reactive to light, and accomodation.
Ears: Normal shape and position with no pits and tags. No discharge
Nose: Nasal septum midline, no nasal flaring but with nasal discharge.
Throat: Moist oral mucosa, no exudates, midline uvula, and no cyanosis.

Neck
No swelling and mass. Trachea in midline.

Chest
Tachypneic, presence of subcostal retraction and fine crackles prominent on the left
upper lung field.; Symmetrical chest expansion.

Heart
Regular heart rate (105 bpm) and regular rhythm, no heaves and thrills; Normal S1 and
S2; No murmurs

Abdomen
Globular abdomen, normoactive bowel sounds, no distention, no masses; tympanitic
abdomen

Genitalia
No phimosis, no discharge, bilaterally discended testes.
Hips
No signsof hip dislocation.

Extremities
Symmetric muscle tone. No clubbing, edema, lesion, and deformities. Evident palmar and
plantar creases.

TrunkandSpine
Spine alignment is normal. No tufts. No sacral dimple.

Anus and Rectum

Anus is patent.

Neurologic
CN I- not assessed
CNII- pupils are equally round, reactive to light and accommodation
CN III, IV, VI- (-) ptosis; (-) limitation of eye movements
CN V- (+) corneal reflex
CN VII- no facial asymmetry
CN VIII- able to respond to sounds
CN IX, X- (+) gag reflex
CN XII- tongue is midline

Negative babinski; Normal muscle tone, no hypotonia, no nystagmus, no atrophy Moves

all extremities equally.

CLINICAL IMPRESSION:
PCAP C Moderate Risk; T/C Atypical Pneumonia