Date and Time of Interview: June 28, 2018 at 11:15 AM

Source of Information: Mother

Reliability: 90%
Source of Referral: Ormoc General Hospital

I. IDENTIFYING DATA
Patient J.B., a 3 year old male patient, born on October 13, 2014, Filipino,
Roman Catholic and residing at Brgy. Libertad Ormoc City, was admitted for the 1 st
time in Eastern Visayas Regional Medical Center (EVRMC) on May 31, 2018 at
around 7:00 PM.

II. CHIEF COMPLAINT

Cough, fever and vomiting

III. HISTORY OF PRESENT ILLNESS

2 weeks prior to admission, the patient had onset of cough and fever
accompanied by vomiting of clear fluid. The mother also noted foul smelling
yellowish brown color ear discharge form the patient. The patient was given
Paracetamol 120 mg suspension every 4 hours which offered temporary relief of
fever. No consultation was done.
1 week PTA, due to recurrence of fever, vomiting and intractable cough,
patient was brought to the Health Center to be checked and was only given Lagundi
syrup for cough which offered no relief. Patient’s mother was advised to increase
fluid intake of the patient.
2 hours PTA, patient still had cough and fever and sudden onset of convulsion
which prompted them to seek consult at Ormoc District Hospital and was admitted on
May 29, 2018 but the patient was referred to EVRMC for better management of the
patient hence admission on May 31, 2018.

IV. PERSONAL HISTORY

A. Prenatal History
The patient was born to a 28 year old G2P2 (2-0-0-2) mother who doesn’t
smoke nor drink alcohol beverages. The prenatal check-up started 1 month AOG
and done monthly until the 8 month AOG at the Health Center conducted by the
midwife. She claimed she only had 1 shot of tetanus toxoid that was after giving
birth of her 1st child. She also took ferrous sulfate which was taken for
approximately 4 months. She did not have any illness and no history of exposure
to radiation, abortion, hypogastric pain, persistent uterine contractions, vaginal
spotting/bleeding and watery vaginal discharge.

B. Birth History
 Patient was delivered at 8 months AOG via normal spontaneous vaginal
delivery assisted by a Doctor at Curva District Health Center in cephalic
presentation with 2 hours of active labor. Umbilical cord was cut using a sterilized
pair of scissors. The umbilical cord sloughed off after 2 weeks. No complications
observed at the umbilical area such as foul smelling, erythema, pus, blood or
watery discharge. Umbilical stump was cleaned everyday using a cotton ball
soaked with povidone-iodine and the mother would wrap a piece of cloth around
the belly (bigkis).

C. Neonatal History
At birth, the patient was pinkish with spontaneous good cry and vigorous
movements. There were no associated dyspnea, fever, convulsion and bleeding.
First stool (meconium) was observed after 12 hours of life which is black, jelly-
like and odorless. The first urine was also passed after 12 hours of life.

D. Feeding History
The patient was exclusively breastfed since birth until 1 year of age, per
demand feeding was done every 2-3 hours, with 15-20 minute duration on each
breast. Patient was bottle-fed at 12 months. Supplemental feeding or solid food
was introduced at 1 year of age consisting of fruits, biscuits and cerelac. He was
also given Ascorbic acid (Ceelin) as vitamins at 6 months of age but for 4 months
only.
24 Hour Diet Recall
I. Before onset of illness
Time Food Calories
Breakfast 1 cup rice 204 calories
1 boiled egg 78 calories
1 glass of water
Lunch 1 cup rice 204 calories
1 matchbox size 185 calories
pork
Snacks 2 pcs sliced 100 calories
bread
Dinner 1 cup rice 204 calories
1 matchbox size 132 calories
fried fish
Total 1,107 calories

II. At onset of illness

Time Food Calories
 Breakfast 1 glass milk 153 calories
½ cup rice 147 calories
porridge with
egg
Lunch 1 cup rice 204 calories
1 matchbox size 185 calories
pork
Snacks 4 pc marie 75 calories
biscuits
Dinner ½ cup rice 147 calories
porridge with
egg
Total 911 calories
During Admission: Fed via NGT
Ideal: 3-year-olds need 1,000 to 1,400 calories per day

E. GROWTH AND DEVELOPMENT

GROSS MOTOR ADAPTIVE FINE MOVEMENTS
-Hand fisted at 1 month -Hands together at 3 months
-Rolls over at 4 months -Grasps objects in hand at 4 months
-Good head control at 5 months -Transfers object from
-Sit with support at 6 months hand to hand at 8 months
-Sit without support at 7 months -Throw toys at 12 months
-Stands holding on at 9 months -Drinks from cup at 15 months
-Walks holding on at 11 -Imitates a circle at 2 ½
months years
-Stands alone at 12
months
-Walks well alone at 15 months
-Runs well at 2 years
-Jumps at 2 ½
years
-Stands momentarily
on 1 foot at 3 years
LANGUAGE PERSONAL SOCIAL

-Laugh at 3 months -Smiles at 1 month

-Moves head -Plays rattle in hand at 4 months
towards sounds at 4 months -Close-open hand
-Imitates sounds at 9 months movement at 8 months
-obeys command -Plays peek-a-boo at 8 months
or request at 12 -Waves bye-bye at 10 months
months -Attempts to use a spoon at 15 months
-Name 1 picture at 2 ½ -Uses spoon at 18 months
years -Washes and dries hands at 3 years
-Tells stories about
Experiences at 3 years
-Counts to 3 or more at 3 years

F. BEHAVIOR
The patient was unconscious when examined but according to the mother
he is friendly. Usually sleeps 7 in the evening and wakes up around 7 or 8 in the
morning. He thumb sucked 15 months old until 2 ½ years old. Nail biting was
also observed at 2 years old.

G. IMMUNIZATIONS
Fully immunized

H. PAST MEDICAL HISTORY

Childhood illness: With history of recurrent ear infections, fever, diarrhea,
cough and colds. No history of chicken pox, measles, mumps, tonsillitis,
gastroenteritis and typhoid fever.
Previous hospitalization: none
Previous surgeries: none
Allergies: String beans
Drug reactions: none
Past blood transfusions: none
Accidents/injuries: none

I. FAMILY HISTORY
Father: 29 years old, works as a farmer, diagnosed with Tuberculosis
Mother: 28 years old, housewife, apparently well.
Siblings: 1 older sister who is currently having cough, colds and fever.
Both maternal and paternal grandparents died of old age. There are
no history of hypertension diabetes, thyroid disease, kidney disease, heart
disease, mental illness, and cancer in the family.

J. PSYCHOSOCIAL HISTORY
The patient belongs to a 4Ps beneficiary family and about to enter school next
year. He interacts well and friendly towards other children and to his older sister. He
lives with his family in a well-lit and well-ventilated house made of concrete
materials situated along the road. Toilet is located outside the house approximately 10
meters away from the house. Water for drinking is from a deep-well in which they
stored in a gallon. They also used water from the deep-well in washing clothes and
dishes. Garbage disposal is disposed through the public pit. They used firewood in
cooking and food is stored in a plastic container. Father is a farmer, smoker and
alcoholic beverages drinker, earns a total income of 250 per day. Mother is a
housewife, doesn’t smoke nor drinks alcoholic beverages.

K. REVIEW OF SYSTEM
General: 25 % weight loss since onset of illness, with fever, no weakness, no
fatigue
Skin: No itchiness, sores, lesions and pallor
Head: No headache, lightheadedness and dizziness
Eyes: No pain, redness, blurring of vision and excessive tearing
Ears: No tinnitus and vertigo, with earaches and discharges
Nose and sinuses: No nasal stuffiness, no nasal discharge, itching and epistaxis
Mouth and throat: Mouth not dry, no hoarseness of voice, no sore throat and
bleeding gums
Neck: with neck pain and rigidity, No lumps
Respiratory: With dyspnea and productive cough of white to yellowish phlegm
amounting to approximately 1 tsp. per expectoration. No orthopnea and
hemoptysis
Cardiovascular: No chest pain, palpitations and cyanosis
GIT: Appetite can’t be assessed because patient is on NGT for feeding, No
nausea, no vomiting, no abdominal pain, no diarrhea/constipation, defecating
once a day with a yellowish brown formed stool
Urinary: No hematuria, polyuria, dysuria, oliguria and nocturia. Fully soaked
diaper changed 3-4x a day.
Genital: No discharges and itching
Peripheral vascular: no leg cramps
Musculoskeletal: no muscle pains, joint pains, backache and weakness
Neurologic: With seizure and loss of consciousness for 3 days, No involuntary
movements
Hematologic: No easy bruising or bleeding tenderness
Endocrine: No excessive thirst and hunger. No heat or cold intolerance
Psychiatric: No nervousness, tension, memory loss, tantrums and mood swings

L. PHYSICAL EXAMINATION
General Survey
Patient was examined lying on bed and unconscious (GCS of 5). Febrile,
with an ectomorph physique and is not on respiratory distress, with the following
vital signs and anthropometric measurements:
 VITAL SIGNS ACTUAL NORMAL
MEASUREMENTS VALUES
Temperature 37.9 36.2 – 37.2 °C
Pulse Rate 138 bpm 65-110 bpm
Respiratory Rate 14 cpm with periods of 20-25cpm
apnea of 8-10 seconds per
minute
Blood Pressure 100/70 Systolic 95-110
Diastolic 60- 75
BMI - -

ANTHROPOMETRIC ACTUAL IDEAL/ PERCENTILE

MEASUREMENTS MEASUREMENTS AVERAGE RANK
Weight - 14 kg
Height 95 cm 95.2 cm
Head Circumference 45 cm 41.5cm
Mid-upper arm circumference 15 cm 15-17 cm
Chest circumference 50 cm
Stunting: (Actual Length/Ht. /Ideal Length/Ht. for age) x 100
(95 cm/ 95.2) x 100= 99.78% Normal: ≥ 95%
Mild: 90-95%
Moderate: 80-90%
Severe: < 80%
Skin
Light brown in complexion, warm, smooth and moist. No rashes, no petechiae, no active
lesions, no scars, no hypo/hyperpigmentation, no central/peripheral cyanosis and
jaundice. No Edema.
Nails: No clubbing or cyanosis

Head
Hair: Short, straight, black in color, fine in texture and equally distributed. No nits or
infestation of lice.
Scalp: No lumps, tenderness, scars, engorged veins, active lesions and dandruff
Skull: Normocephalic and atraumatic, temples not distressed
Eyes
Eyebrows: Symmetrical, fine in texture, black and equally distributed
Eyelashes: Fine in texture, black and oriented outwards
Eyelids: No edema, ptosis, lid lag and sty
Conjunctiva: Pinkish palpebral and bulbar conjunctiva, no hemorrhage
Sclera: clear and anicteric, no hemorrhage
Cornea: NO ulcerations, no opacities
Pupils: symmetrical, approximately 2 mm in diameter, equally round and reactive to
direct and consensual light stimulation and accommodation
EOM: undetermined

Ears
Symmetrical in shape and alignment, firm pinna, with yellowish brown ear discharge on
left ear

Nose
No discharge, no septal deviation, no epistaxis and nasal flaring (Not completely
examined due to presence of nasal cannula)

Mouth and throat

Lips: Pinkish, moist, no angular deviation, cold sores and cuts
Mucous membranes: Moist, no bleeding, with oral ulcers
Gums: Pinkish and no bleeding
Teeth tongue and throat: (Not completely examined due to unconsciousness of the
patient and having a hard time opening the mouth)

Neck
Trachea is in midline, thyroid gland not palpable, no engorged veins and visible
pulsations, no lymphadenopathy
Breast
Symmetrical, no lumps or discharges

Chest and Lungs

Inspection: Truncal in shape, symmetrical, no subcostal or intercostal retraction, no
bulging, no lesions and lumps
Palpation: Symmetrical chest expansion, no masses, tactile fremitus can’t be assessed
because patient is unconscious
Percussion: Resonant on all lung fields
Auscultation: Crackles upon auscultation with 8-10 seconds of apnea per minute, no
rales, and no wheezing and pleural friction rub

Heart
Inspection: No precordial bulging, visible pulsations, and lumps.
Palpation: Apex beat palpable at 5th left ICS at MCL. No thrills and heaves.
Auscultation: No murmurs, bruits, and precordial friction rub.
Abdomen
Inspection: Flat in configuration. No visible peristalsis, engorged veins, and hyper and
hypopigmentation. No bulging and inverted umbilicus.
Auscultation: Normoactive with 10 bowel sounds per minute. No arterial bruit, venous
hums and peritoneal friction rub
Percussion: Tympanitic on all quadrants
Palpation: Soft, and non-tender. Liver, spleen, and kidneys not palpable, no intra-
abdominal or muscular masses
.
Extremities
Symmetrical and equal in length, no edema, no lesions, left arm rigidly extended with
internal rotation of wrist, left lower extremities also rigidly extended with plantar flexion
of foot
Brachial: R: 2+ L: 1+
Radial: R: 2+ L: 1+
Femoral: R: 2+ L: 1+
Popliteal: R: 2+ L: 1+
Posterior tibial: R: 2+ L: 1+
Dorsalis pedis: R: 2+ L: 1+

Back and Spine

There are no abnormal deviations. No retraction, bulging, and paravertebral tenderness or
mass.

Genitalia
Not observe

M. NEUROLOGIC EXAM
Mental Status Exam: Patient is unconscious (GCS of 5)

Cranial Nerves:
CN I: Unable to examine because patient was unconscious
CN II: Pupils are 2 mm in diameter, reactive to light stimulation and
accommodation. (Unable to completely examine the cranial nerve because
patient was unconscious)
CN III, IV, VI: (Unable to completely examine the cranial nerve because patient
was unconscious)
CN V: No facial sensation to pain and touch, absent corneal reflex
CN VII: (Unable to completely examine the cranial nerve because patient was
unconscious)
CN VIII: (Unable to completely examine the cranial nerve because patient was
unconscious)
CN IX & X: (Unable to completely examine the cranial nerve because patient
was unconscious)
 CN XI: (Unable to completely examine the cranial nerve because patient was
unconscious)
CN XII: (Unable to completely examine the cranial nerve because patient was
unconscious)
Motor
(Unable to completely examine the motor function because patient was unconscious)

Sensory
Doesn’t withdraw hand where pain stimulus is applied. (Unable to completely examine
the sensory function because patient was unconscious)

Reflexes
Primitive Reflex: (Unable to completely examine the reflex because patient was
unconscious)
Superficial reflex: (-) abdominal reflex

Deep Tendon Reflexes:

2+ 0+

2+ 0+
2+ 0+

2+ 0+

2+ 0+

Pathologic Reflexes: (-) Babinski, (-) Clonus

Cerebellum
(Unable to completely examine the cerebellar function because patient
was unconscious)

Meningeal
(+) Nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski sign

Autonomics
 No excessive sweating and no urinary incontinence

Diagnosis: Meningitis
Basis for diagnosis:
 Hx of recurrent ear infection
 Current ear infection
 Seizure
 Fever
 Stuporous, difficult to wake (GCS of 5)
 Vomiting
 Nuchal rigidity
 Decerebrate posturing