Cagayan State University- Carig Campus

College of Medicine and Surgery

PEDIATRICS WARD
PRESENTED BY: RICH MARK T. CONAG
CASE #2 JODEX MARIE DACAYO
PEDIA DE CURIE: SEPTEMBER 22,2017
JHOE ANNA MARIE TANGO
PRECEPTOR: DR. MA. CONSUELO MANUEL
RONALDO ZABALA

IDENTIFYING DATA
Name: MG
Age: 8 y/o
Sex: Female
Religion: Roman Catholic
Address: San Pablo Isabela
Number of Admission/s: 3
Present Hospital of Admission: Cagayan Valley Medical Hospital
Date of Admission: September 19 2017
Informant: Patient and Mother
Reliability: 100%

CHIEF COMPLAINT Generalized Edema

HISTORY OF PRESENT ILLNESS

February 2017, Seven months prior to admission patient was observed by the mother to have
swollen peri-orbital edema and edema on both legs. This was accompanied by high fever and
nonproductive cough. These were attempted to be treated at home for three days with Paracetamol
syrup of 1tbsp a day and with complete bed rest however the signs and symptoms didnt subside. It was
then on the fourth day that parents rushed her to the nearest local hospital (NAME) hence admitted and
confined for 2 consecutive days.

May 2017, Four months prior to admission, patient was seen with generalized edema that lasted
for three days but because of financial constraints the family opted to have her attended at home. This
was also aggravated by difficulty which according to the mother, this is related to her asthma diagnosed
since childhood and they were able to manage it with salbutamol via nebulization. They attempted to
have her consulted at the nearest center where the family was just advised to limit intake of salty foods
and water which they relied on to manage symptoms of edema.

Four days prior to admission the patient showed signs of generalized edema, cried for help upon
waking up in the morning because of difficulty of breathing and limited movement with high fever. The
parents attempted to resort to home medications and treatment such as oral Paracetamol syrup 1tbsp
every four hours and restriction of oral fluid intake however symptoms constantly risen up. This
prompted the parents to bring her to CVMC on the evening of September 09, 2017, hence admitted.

PAST MEDICAL HISTORY:

The patient had been previously diagnosed with asthma by their community doctor and has
been on salbutamol via nebulization since the age of 4. They secured their own nebulizer kit at home
and thus used as needed According to the mother, MG is oftenly triggered by pollen or an allergens and
said once a week for the past year is a normal frequency.

Patient MGs first medical confinement was on February (mother could not recall exact date)
which is related to present complaint was at their local hospital and lasted for 2 days. This was followed
by another hospitalization on May for same symptoms. Third hospitalization is the current.

The mother also recalled that the child suffered from chicken pox when she was 6 years old
however could not recall management and treatment given.

PERSONAL AND SOCIAL HISTORY:

Patient is the youngest in a brood of three. Her father is _ year-old and Mother is _ year old and
both work as farmers. The family lives in a semi concrete house with 3 rooms. The patient is a grade 3
pupil and was described jolly and bright.
The mother also describe their economic status as average but had been living healthy and
sufficed by 3 meals per day however admitted not being able to resort to hospitalization of her child into
some instances. The patient has no allergies so she eats anything that is available and served.

FAMILY HISTORY:

No known hereditary, familial or childhood diseases from both sides like Asthma, no allergies to
any food or drugs.

Family history: Paternal Maternal

Ca - -

HPN + +
DM - -

Heart Dse. - -