FAR EASTERN UNIVERSITY – DR.

NICANOR REYES MEDICAL FOUNDATION

Regalado Ave., cor. Dahlia St., West Fairview, Quezon City, 1118
Tel. No.: 427-0213
Department of Child Health

Clinical History

General Data:
FG, 11-month-old female, born on July 17, 2020 in Quezon City, admitted for the first time on July 3, 2021.

Chief Complaint: fever for 11 days

History of Present Illness:

Ten days prior to admission, she was warm to touch and with watery nasal discharge. There is no associated
cough, loose stools, or vomiting. She still had good appetite and activity. No medications were given and no consult
was done.
Nine days prior to admission, now with fever with the highest temperature of 38.2 oC, still watery nasal
discharge. There is still no associated cough, loose, stools, or vomiting and still with good appetite and activity. She
was given Paracetamol (8.8mg/kg/dose) which temporarily lysed the fever. No consult was done.
In the interim, she still had episodes of intermittent fever with the highest temperature of 39 oC and watery nasal
discharge, still with good appetite and activity. Paracetamol (8.8m/kg/dose) was given every 6 hours which
temporarily lysed her fever.
Until five days prior to admission, due to the persistence of fever, they now sought consult to a private
pediatrician. Complete blood count with platelet count was noted to be leukocytic with neutrophilic predominance.
The diagnosis was unrecalled and she was given Co-Amoxiclav twice a day (39mg/kg/day), Paracetamol
(10.6mg/kg/dose), and Cetirizine drops. The patient was compliant with her medications however, she was still noted
to have febrile episodes with the highest temperature of 39 oC but now with lesser nasal discharge.
Until two days prior to admission, still with episodes of fever, and with lesser nasal discharge, she now had
three episodes of watery based stools. She was noted have decreased appetite and activity. Still no associated
cough and vomiting. Her medications were continued.
One day prior to admission, still febrile with the highest temperature of 39 oC, with four episodes of watery
based stools, and still with decreased appetite and activity. They now consulted in the Emergency Room with a
diagnosis of Acute Gastroenteritis probably viral; Some Dehydration-Moderate; Reactive Lymphadenopathy, Right;
COVID Suspect, rule out sepsis. She was advised admission but they opted to be discharged against medical
advice. COVID RT-PCR and other tests were refused.
Few hours prior to admission, still was still febrile with the highest temperature of 39 oC, with three episodes of
watery based stools, still with decreased appetite, and activity. She has no more tears. She was again brought to the
Emergency Room and was subsequently admitted.

Neonatal History:
She was born to a 29-years old Gravida 3 Para 3 (2103) at 8 months age of gestation delivered via normal
spontaneous delivery at Quezon City General Hospital. Her mother was noted to be febrile and had slight difficulty of
breathing at the time of her birth and her COVID RT-PCR was positive. Her mother was admitted for 14 days in the
isolation ward after delivery. Two COVID RT-PCR done on the patient’s 24 th hour of life and 2nd day of life were both
negative.

Past Medical History:

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 No history of seizure or known allergies to food or medications. At birth, she was treated for sepsis with
Ampicillin, Gentamycin, Vancomycin, and Ciprofloxacin. She also underwent phototherapy during her stay at the
Neonatal Intensive Care Unit.

Immunization History:
Her immunizations were administered in a local health center:
BCG- 1 dose at birth
Hepa B- 1 dose at birth
Pentavalent Vaccine (DPT-HepB-Hib)- 3 doses
OPV- 3 doses
IPV- 1 dose
PCV- 3 doses
MMR- 1 dose

Developmental History:
Gross Motor Fine Motor Social Language
Smiles
2mos
responsively
3mos Head control
4mos Rolls over Laughs
Can sit without Transfers object Babbles
6mos
support hand to hand
10-11mos Pulls to stand Holds toys Says mama

Family History:
Father, 28-years old, Regional Account Manager for United Healthcare Inc., known Hypertensive and is
maintained on Amlodipine. He tested positive for COVID-19 and was also sent to a quarantine facility for 14 days. He
was asymptomatic at that time.
Mother, 29-years old, works as an Analyst, and was diagnosed with Systemic Lupus Erythematosus during her
third pregnancy. Once she recovered from COVID-19, she was given Methylprednisolone from November 2020 to
June 2021. She is still on constant follow-up with her private Rheumatologist.
Two older brothers, 10-years old and 7-years old, are both well. Both children tested negative for COVID-19
last year.

Personal and Social History:

They live in a two-storey house with three bedrooms. There are nine people in their household: the maternal
grandparents, eldest and younger sister of the mother, the patient’s parents and two siblings. The rest of the
household tested negative for COVID-19. The patient’s family sleeps in a single bedroom.
Both parents are financial providers and currently works from home. The primary caregiver is the mother. None
had the same manifestations prior to the patient’s illness.

Nutritional History:
She was given donated breastmilk during her stay at the NICU and was eventually given formula milk once the
patient was discharged. Currently, she now eats mashed fruits or vegetables and is still given formula milk.

Physical Examination upon Admission at the Ward

General Survey: awake, irritable, with some signs of moderate dehydration
CR: 146bpm RR: 37cpm Temp: 36.5oC
Weight: 11.3kg IBW: 8.5kg

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HEENT: decreased tears, sunken eyeballs, pink palpebral conjunctiva, white sclera, both ears with patent canals and
with intact tympanic membrane, both nostrils with whitish mucoid discharge, dry lips, moist buccal mucosa, slightly
hyperemic pharyngeal walls, 6 x 4cm firm, non-erythematous, non-movable, not warm to touch, palpable mass on the
right submandibular area
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmur
CHEST/LUNGS: Symmetrical chest expansion, no retractions, occasional crackles, good air entry
ABDOMEN: soft, slightly globular abdomen, no mass, no organomegaly, hyperactive bowel sounds
EXTREMITIES: No gross deformities, full and equal pulses, CRT <2seconds
NEUROLOGIC EXAM: GCS 15/15 (E4V5M6)
CN I- not assessed
CN II- 2-3mm equally reactive to light
CN III, IV, VI- follows movement of toys
CN V- bites tongue depressor
CN VII- no facial asymmetry
CN VIII- turns head when name is called
CN IX, X- can swallow milk
CN XI- can turn head side to side
CN XII- tongue at midline

Motor: DTR:

5 5 +2 +2

5 5 +2 +2

Negative for Babinski, Clonus

Negative Kernig’s and Brudzinski sign

Imaging/ Laboratory Results

Contrast CT-Scan of the Neck (July 10, 2021)

Several Enhancing cervical lymph nodes, some of which are peripheral enhancement, largest of these is seen in
the right anterior triangle (Level II-III) measuring 4.6 x 2.9 x 4.6cm with peripheral enhancement and central
necrotic densities. This lesion is seen compressing the ipsilateral jugular vein and displacing the
sternocleidomastoid posteriorly. Few unenlarged to prominent size lymph nodes are likewise noted in the left
upper to middle jugular vein, largest seen in the upper chain measuring 0.8 x 0.9 x 0.7cm. The oral floor muscles
are bilaterally symmetrical and normally developed. Imaged portion of the parotid, thyroid, and submandibular
glands grossly show no abnormalities. The oropharynx and glottic are unremarkable. The visualized brain
parenchyma is unremarkable.
Impression: Infective cervical lymphadenopathies with peripheral enhancement and central necrotic hypodensities,
right. Primary Consideration is Infectious process such as scrofula from Pulmonary Tuberculosis
Neck Ultrasound (July 7, 2021)
There are multiple enlarged cervical lymph nodes seen in the right lateral neck with one appearing to be a
confluent lymph node that is heterogenous in appearance measuring 4.0 x 4.8 x 3.2cm at level IB to II. This
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confluent lesion also shows cystic degeneration and have peripheral vascularity. Unenlarged cervical lymph nodes
are also observed. The parotid and submandibular glands are normal in size with homogenous parenchymal echo
pattern.
Impression: Consider conglomerate enlarged cervical lymph nodes, right, with cystic degeneration, cannot rule out
abscess formation. Unenlarged cervical lymph nodes in the left. Normal thyroid, parotid, and submandibular
glands sonographically

June 28, 2021 July 3, 2021 July 7, 2021 July 10, 2021 July 15, 2021
Peripheral Blood Smear (July 5, 2021)
Hgb 11.6 12.6 12.6 12.0 11.5
Normocytic, Normochromic
Hct 34 RBC. There38.2
is leukocytosis 37.6
with 35.9 34.6
predominantlyPltneutrophils246 with toxic granules
562 and cytoplasmic
620 vacuoles.459 349
There is shiftWBC
to the left with
11.9stabs and metamyelocytes
24.96 seen. Platelets16.67
23.24 13.87
are slightly increased
Neut but 72
has normal morphology.
50.3 Blasts are not seen. 66.6
46.5 20.6
Lymph 20 36.9 39.7 21.8 72.5
Mono 2 11.0 11.7 11.0 4.2
Eos 6 1.7 0.2 0.2 2.6

July 4, 2021 July 3, 2021

Color Straw Character Watery Mucoid
Character Clear Color Yellow
pH 9.0 pH Acidic
Sp.Gr. 1.008 Parasites/Ova None
Protein Negative Pus Cells 0-1
Glucose Negative RBC 0-1
Pus Cells 11.8
Salmonella Typhi July 3, 2021
RBC 2.2
IgM Non-reactive
CRP (mg/L) IgG Non-reactive
July 3, 2021 326.8
July 7, 2021 154.5 Chest Xray (July 2, 2021)
July 10, 2021 121.64 Pneumonia, Right
July 15, 2021 16.59
Gene Xpert of Aspirate (July 13)
July 3, 2021 MTB not detected
ESR (0-20) 12mm/hr
Blood CS (July 3, 2021) AFB Staining of Aspirate (July 13)
No growth after 5 days Negative
Gram Stain and Culture of Aspirate (July
PPD (July 3, 2021)
13)
0mm
More than 100 pus cells/ hpf;
July 9, 2021 No growth after 48 hours
Creatinine 29umol/L

COVID RTPCR (July 2, 2021)

Non-reactive 4
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