Date: August 14, 2023 Informant: Mother

Time: 2:00 PM Percent Reliability: 80%

General Data:
Z.B.B., 1 year old, Male, Filipino, Roman Catholic, born on May 25, 2022, at Pampanga,
currently residing at Unit 5 Pugo Street, Barangay Commonwealth, Quezon City. Admitted for the 1st
time at FEU-NRMF on August 14, 2023.

Chief Complaint: Fever and loose stools of 8 days

History of Present Illness:

8 days prior to admission, the patient was noted with 10 episodes of yellowish, mucoid, watery
loose stools (Bristol Type 7) amounting to moderately soaked diapers every after feeding, with the first
one noted with blood streaks. Patient was also noted with colds, with clear watery nasal discharge. No
associated signs and symptoms such as thirst, vomiting, fever or cough. Noted to have good activity and
appetite, and adequate frequency of urination. No medications taken and no consultation was done.

7 days prior to admission, the loose stools of 10 episodes and colds persisted, now accompanied
by dry, infrequent, non distressing cough and intermittent fever (Tmax 39C - axillary). No associated
signs and symptoms such as thirst or vomiting.The patient was noted to be irritable and with decreased
appetite from consuming 1 cup to ¼ cup serving and only tolerated drinking milk. With adequate
frequency of urination, 8 times a day, mildly soaked diaper. The patient was given Paracetamol (Tempra)
100mg/ml, 1.3ml (Td: 14.4 mg/kg/dose) every 4 hours which afforded lysis of fever. Due to the
persistence of the symptoms, the patient was brought to his private pediatrician in Pampanga. Fecalysis
was requested, revealing presence of Entamoeba histolytica. With the impression of amoebiasis, he was
prescribed with Metronidazole 125mg/5ml, 4.5mL TID (Td: 37.5mg/kg/dose), Zinc Sulfate 10mg/ml, 2ml
OD (Td: 20mg/day), and ProIG 1 sachet once a day. With no noted relief of symptoms.

6 days prior to admission, the patient had 7 episodes of loose stools (Bristol Type 6) amounting to
2 tsp per bout, intermittent fever (Tmax 38C), cough and colds. No associated signs and symptoms such
as thirst or vomiting The patient was given the same medications, which allegedly provided relief of
symptoms. Noted with better activity and appetite. No consultation was done.

5 days prior to admission, the patient had 5 episodes of loose stools (Bristol Type 6) amounting to
2 tsp per bout, intermittent fever (Tmax 38C) and colds. No associated signs and symptoms such as thirst
cough or vomiting. The patient was given the same medications, which allegedly provided relief of
symptoms. Noted with better activity and appetite. No consultation was done.

4 days prior to admission, the patient had 4 episodes of loose stools (Bristol Type 6) amounting to
2 tsp each bout, intermittent fever (Tmax 39C) and colds. No associated signs and symptoms such as
thirst cough or vomiting. Noted with decreased activity and appetite consuming 1 cup to only tolerating
formula milk. Due to the persistence of symptoms, the patient brought again to his private pediatrician,
where he was prescribed with Cotrimoxazole 40mg/200mg/5ml, 4ml BID (Td: 7.11 mg/kg/dose) and
Bacillus Clausii (Erceflora), one vial BID. ProIG was discontinued. The patient took the medications
which provided relief.

3 days prior to admission, the patient had 3 episodes of loose stools (Bristol Type 6) amounting to
1-2 tsp each bout, intermittent fever (Tmax 38C) and colds. No associated signs and symptoms such as
thirst cough or vomiting. Noted with better appetite and activity, and adequate frequency of urination.
 2 days prior to admission, the patient had 4 episodes of loose stools (Bristol Type 6) amounting to
1-2 tsp each bout, intermittent fever (Tmax 38C) and colds. No associated signs and symptoms such as
thirst cough or vomiting. Noted with better appetite and activity, and adequate frequency of urination.

1 day prior to admission, the patient had 4 episodes of loose stools (Bristol Type 6) amounting to
1-2 tsp each bout, intermittent fever (Tmax 38C) and colds. No associated signs and symptoms such as
thirst cough or vomiting. Noted with better appetite and activity, and adequate frequency of urination.

Few hours prior to admission, due to the persistence of the symptoms, the patient was brought
again to his pediatrician for follow up. With an impression of enteric fever, he was then advised to be
admitted to his hospital of choice, and referred to an Infectious Disease Specialist, hence consulted in our
institution and was subsequently admitted.

Prenatal/Maternal History:
The patient was born to a 29-year-old G1P1 (1001) mother. Pregnancy was unplanned. The
mother had regular prenatal checkups and regular intake of prenatal medications including Multivitamins,
Folic Acid, Ferrous Sulfate, Calcium, and Vitamin D. The mother was diagnosed with hyperthyroidism
during the 1st trimester, maintained on unrecalled medications.The mother had no history of diabetes
mellitus and hypertension during her pregnancy. No other maternal illness was noted. No exposure to x-
rays, and injurious toxins such as smoking and alcoholic beverages.

Birth History:
The patient breathed spontaneously upon birth and was delivered via cesarean section in a private
hospital in Pampanga. The patient was born term. Birthweight and APGAR scores were unrecalled.

Past Medical History:

 (+) Neonatal sepsis - 2 weeks old admitted at Garcial Hospital in Pampanga
 (+) Pneumonia - Feb 2023 admitted at St John Paul Hospital in Pampanga
 (+) Amoebiasis - at 5 months and 9 months old
 (+) GERD - 2023 given Esomeprazole with unrecalled dose
 No known allergies
 No history of asthma
 10-11x cough and colds a year
 No history of chicken pox, mumps or measles
 No G6PD deficiency
 No history of tuberculosis
 No previous surgery and blood transfusion
 No history of accidents, previous operation

Family History:
 Father: 29 years old, office worker apparently well
 Mother: 29 years old, unemployed, diagnosed with hyperthyroidism last 2019 with unrecalled
maintenance medication, non compliant.
 With family history of hypertension on mother side
 No other heredofamilial diseases such as heart, kidney, or liver diseases, malignancy

Immunization History:

Immunization Dose Place of Immunization

 Hepatitis B 3 doses

Rotavirus 2 doses

DTaP 3 doses

Polio 3 doses

BCG 1 dose

HiB 3 doses
Private Pediatrician
PCV13, 15 3 doses

IPV 2 doses

Flu Influenza 2 dose

MMR 1 dose

HepA 1 dose

Personal and Social History:

The patient lives with his mother, aunt, and maternal grandparents in a well-ventilated two storey house.
The main financial provider is his aunt. His mother and grandmother are the main caregivers. He likes
playing toys with the family members in his free time. Their water supplier is Maynilad and the patient’s
drinking water is mineral water. Garbage is segregated and collected two to three times a week.

Nutritional History:
The patient was started with formula mik (Nan Optipro, Nan Sensitive, Nan AL110, Enfamil and
Enfagrow) since birth. Complementary feeding started at 8 months old consisting of soup and mashed
foods. The patient’s current diet includes 1 cup of rice with 1-2 viands per meal and eats 3 meals per day
with snacks in between. The patient prefers to eat kalabasa, sayote, fish and chicken.

Developmental History:

Gross Motor Fine Motor Language Social Cognitive

2 Strong grip Can hold head Turns head Smiles Follow things
months up toward sounds Looks at with eyes
parents
Make gurgling Alert to sounds
noises

4 Sits with support Reaches for Turns to voice, Smile

months objects name

6 Lifts head Holds own Imitates

months bottle actions

8 Can crawl Holds own Can speak papa

 months bottle and mama

11 Can walk and stand Understands no Looks at picture

months with support presented to her
Dances to music

12 Stands well with Holds crayon Points to get

months arms high desires object
Attempts tower
Independent steps of two cubes

PHYSICAL EXAMINATION

General Survey: The patient is awake, irritable, with some dehydration with the following vitals signs:

BP: - HR: 130 bpm RR: 24 cpm Temp: 37.7C O2 sat: 97%

Wt: 9 kg Length: 83cm IBW: 10 kg

Weight-for-age: Between 0 and -1 (Normal)

Height-for-age: +2 (Normal)
Weight-for-length: -2 (Normal)
HEENT: Pink palpebral conjunctiva, white sclera, intact tympanic membrane, (+) congested turbinates,
dry lips and buccal mucosa
CHEST/LUNGS: Symmetrical chest expansion, no retractions, clear breath sounds, good air entry
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmurs
ABDOMEN: Flat, soft abdomen, normoactive bowel sounds, no tenderness noted on all quadrants, no
palpable masses, no organomegaly
EXTREMITIES: No gross deformities, full and equal pulses, CRT < 2 seconds
GENITALIA: Not assessed
SKIN: Skin is fair, no active dermatoses, normal skin turgor

NEUROLOGIC EXAM:
Cerebrum: awake, alert, GCS 15 (E4V5M6)
Cerebellum: Intact; no nystagmus
Cranial Nerves:
 I: not assessed
 II: pupils are equally reactive to light
 III, IV, VI: no ptosis, intact extraocular muscles
 V: can open and close mouth
 VII: no facial asymmetry, able to close eyes, can smile
 VIII: turns head to noise
 IX & X: uvula at midline
 XI: can turn head side to side and able to elevate shoulders
 XII: tongue at midline
Signs of meningeal irritation: No nuchal rigidity, No Kernig’s sign, No Brudzinki’s sign

5/5 5/5 100% 100% +2 +2

5/5 5/5 100% 100% +2 +2

MOTOR FUNCTION SENSORY FUNCTION DEEP TENDON
REFLEXES