BULACAN MEDICAL CENTER

City of Malolos
DEPARTMENT OF PEDIATRICS
WARD CLINICAL HISTORY FORM
INFORMANT: Mother
RELIABILITY: 90%
GENERAL DATA:
This is a case of patient Reyes, Chrisalyn, 15 years old, female, single, student, Filipino, Catholic, born on December 14, 2002, currently
residing at Brgy. Camachilihan, Bustos, Bulacan, admitted to our institution for the 2 nd time.

CHIEF COMPLAINT: Difficulty of breathing

HISTORY OF PRESENT ILLNESS:

Patient was apparently well until 2 days prior to admission when patient developed sudden-onset body weakness, described as ascending
beginning from both lower extremeties and spreading towards the lower part of the upper body, both front and back. This was associated with a single
bout of vomiting, 2 cups, watery and of previously ingested food, non-bloody, non-billous, non-projectile, not associated with abdominal pain, fever,
dizziness or difficulty of breathing. This was accompanied by loose stools described to be yellow-green in color, watery in material with few semi-formed
stool and non-foul smelling, non-bloody and non-mucoid and about ½ cup in volume. Patient was then brought to Bustos Hospital where she was given
Oresol and an unrecalled multivitamins.
1 day prior to admission, patient’s body weakness of same character and quality still persisted, now no longer associated with vomiting and
loose stools. Patient developed difficulty of breathing. No consult was done but patient continued the previously prescribed medications.
Few hours prior to admission, with the persistence of the body weakness, patient sought consult again at Bustos Hospital and was then
advised to seek consult at our institution due to lack of facilities. Hence, the admission.

OB-GYNE HISTORY:
Menarche: 14 years old Duration: 5 days Symptoms: (-) Dysmenorrhea
Interval: Regular, 28 days Amount: 8 pads/day, minimally-soaked (-) PMS

PAST MEDICAL HISTORY:

Common Diseases
(-) Dengue (-) Urinary tract infection
(-) Measles (-) Chickenpox
(-) Rubella (-) Mumps
(-) Bronchial Asthma (+) Animal bite dog, 2010

IMMUNIZATION HISTORY:
VACCINE NO. OF VACCINE NO. OF
DOSES DOSES Previous hospitalization: Two previous hospitalizations due to hypokalemia
BCG 1 HEPA A - Specific Allergies: None
Pulmonary Tuberculosis: None
HEPA B - MEASLES - Drugs and duration of treatment: None
DPT 3 MMR - Deworming: None
OPV 3 INFLUENZA -
Dengvaxia: None

FAMILY HISTORY:
Hereditary/ Familial Diseases:
(-) Hypertension
(-) Asthma
(-) Diabetes Mellitus
(-) Allergy, Seizure disorder
(-) Tuberculosis
(-) Heart Disease, Kidney Thyroid diseases

PERSONAL & SOCIAL HISTORY:

Residence and Community: Bungalow-type house, well-ventilated, living with parents
Cooking: Wood-powered stove
Source of Water for Drinking: Purified/distilled water
Toilet Facility: pour type
Garbage Disposal: Collected every Wednesday by garbage collector, well segregated
Within the vicinity: no nearby factory or piggery; nearby creek and river
Prevalent Disease in the Community: Dengue

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 BULACAN MEDICAL CENTER
City of Malolos
DEPARTMENT OF PEDIATRICS
WARD CLINICAL HISTORY FORM

GROWTH & DEVELOPMENTAL HISTORY

H – Harmonious family relationship
E – Active in school, average
A – Enjoys surfing the internet
D – No illicit drug use
S – No sexual partners/ sexual practices
S – Spiritually connected
S – No suicidal ideations

REVIEW OF SYSTEMS:
GENERAL: (-) weight loss (-) chills (-)malaise
INTEGUMENTARY: (-)discoloration (-)lesions (-)pruritus
HEAD AND NECK: (-)lesions (-) diplopia (-)ear pain
(-)sore throat (-)disturbance of taste
Respiratory System: (-) back pain (-)cough
Cardiovascular System: (-)PND (-)easy fatigability
Gastrointestinal Tract: (-)dysphagia (-)odynophagia (-)odynophagia
(-)hematemesis (-)hematochezia (-)hemoptysis
Genito-urinary Tract: (-)dysuria (-)anuria (-)polyuria
(-)hematuria (-)incontinece (-)discharges
(-)flank/suprapubic pain (-)dribbling (-)urinary frequency
Hematologic: (-)easy bruisability
Endocrine: (-)polyuria (-)heat/cold intolerance
Neuropsychiatric: (-)syncope (-)paralysis (-)depression
(-)loss of memory (-)delirium
(-) hallucinations (-)tremors
Neuromuscular System: (-) muscle pain (-) atropy (-) joint pain
(-) back pains (-)involuntary muscular movement

PHYSICAL EXAMINATION:
General Survey: Patient was conscious, coherent, and ambulatory, cooperative, not in cardiorespiratory distress, with colostomy at left lower quadrant
and IVF at left hand of PNSS 1L + 20 mEq KCl x 12 hours with the following vital signs:
AT THE ER:
Vital signs: BP: 100/70 mmHg HR: 123 bpm RR: 24 cpm Temperature: 36.4 O2sat: N/A
AT THE WARD:
Vital signs: BP: mmHg HR: 78 pm RR: 22 cpm Temperature: 36.7 O2sat: 98%
Anthropometric measurements:
Actual weight: 53.5 kgs. Height: 16.15 feet
Z-score:

SKIN
Brown in color, no lesions, no abnormal pigmentations, no rashes, no birthmarks, no jaundice, warm to touch, moist skin, good skin
turgor.

HEENT
Head is normocephalic, anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, no masses, (-) tonsillopharyngeal
congestion, (-) cervicolymphadenopathy, (+) dry lips, (+) whitish plaques on tongue

Chest and Lungs

No mass, no lesions, no visible subcutaneous vessels, no nodules, no hypo/hyperpigmentation, symmetrical chest expansion,
(-) intercostal/subcostal retractions, (-) lagging, vesicular breath sounds

Heart
No mass, no lesions, no visible superficial veins, no nodules, adynamic precordium, normal rate, regular rhythm, apex beat at 5 th left
intercostals space midclavicular line, no murmurs

Abdomen
Flat abdomen, soft, non-distended, normoactive bowel sounds, no masses, (-) tenderness upon deep and light palpation, no
organomegaly, with patent colostomy on left lower quadrant with greenish semi-solid output of about 125 L

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 BULACAN MEDICAL CENTER
City of Malolos
DEPARTMENT OF PEDIATRICS
WARD CLINICAL HISTORY FORM

Extremities
No gross deformities, no edema, (-) for cyanosis, full equal pulses, CRT <2secs, no deformities

Genitourinary:
Not assessed

Neurologic Examination
GCS 15 (E4M6V5)
Sensorium: Awake, alert
Cranial Nerves:
I: not assessed
II: Pupillary size: 2-3 mm, equally reactive to light
III, IV, VI: intact EOM
V: can clench teeth
VII: no facial asymmetry
VIII: can hear bilaterally
IX, X: uvula is at the midline
XI: can shrug shoulders
XII: can protrude tongue

Motor Function: Sensory Function:

3/5 3/5
100% 100%

2/5 2/5 100% 100%

Deep tendon reflexes: +2

Meningeal signs: (-) nuchal rigidity, (-) kernig’s sign, (-) brudzinsk’s sign

IMPRESSION: Hypokalemic Periodic Paralysis

PLAN: Admit to Female Adolescent

DIET: High potassium diet
IVF: Plain Lactated ringer to run at 30 gtts/min. for 2 hours then refer
DIAGNOSTICS: CBC with APC
Urinalysis
Fecalysis
Serum Na, K, Ca, Cl
MEDICATIONS: 1. K-lyte tab TID

PINEDA, Roger Carlo P.

__________________________________ September 2, 2018
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 BULACAN MEDICAL CENTER
City of Malolos
DEPARTMENT OF PEDIATRICS
WARD CLINICAL HISTORY FORM
Resident In-Charge Clerk In-Charge Date Accomplished

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