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Pediatric Case

Presentation

Group 2 B:

Alfelor; Thapa; Gurung; Go; Ortiz; Corachea

General Data

Jocel Reminal, 18 years old, male, Roman Catholic


from Polangui, Albay.

Informant: Patient and Mother of patient


Reliability: 95%

1/19/17

Group 2B Rhambdomyosarcoma

Chief Complaint: Left


Infraorbital Pain

HISTORY OF PRESENT ILLNESS

10 months PTC:
o Hit on the left infraorbital surface of his face
o Pain on the left infraorbital area (pain scale 5/10)
o Left eye: erythematous and pruritic without discharge
o Ice pack was placed on the affected area for pain relief for two weeks.
o No consult done and medication taken.

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Group 2B Rhambdomyosarcoma

History of Present
Illness

9 months and 3 weeks PTC


o erythematous and pruritic left eye still persisted
o Pain in the infraorbital area also persisted
o Red tissue bulging out from left eyelid
o no improvement of symptoms
o self-medicate with Amoxicillin 500 mg tablet, once a day for a month
o no relief was achieved

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Group 2B Rhambdomyosarcoma

History of Present
Illness

8 month and 3 weeks PTC


o Red tissue bulging out of the left lower eyelids progressively increasing in size
covering the of the left eye
o Eye erythema and pruritus
o Left infraorbital eye pain progressed to a pain scale of 10/10
o Seek consult at Legaspi Eye Center
o Referred to UPPGH to have a biopsy, blood tests, CT scan and MRI
o Tramadol 50 mg tablet every 4 hours was prescribed for pain relief.
8 months and 2 weeks PTC: went to UPPGH and was biopsied, blood tested and MRI.
8 months PTC: diagnosed to have Stage 4 Alveolar Rhabdomyosarcoma.
o advised to start chemotherapy and radiation treatment as soon as possible.
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Group 2B Rhambdomyosarcoma

History of Present
Illness

From 8 months until 5 months PTC:


o Able finish 7 cycles of chemotherapy and radiation therapy
o Nausea, vomiting, hair loss and anorexia
4 months and 3 weeks PTC:
o Relief from symptoms
o Regression of bulging red tissue on the lower left eyelids.
From 4 months to a month PTC:
o Patient was not able to continue the chemotherapy and radiation
therapy.

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Group 2B Rhambdomyosarcoma

History of Present
Illness

A month PTC:
o Symptoms of left infraorbital pain recurred
o Bulging tissues from left lower eyelid is progressively enlarging
o Patient to decide to continue the chemotherapy and radiation cycle.
On the day of consult: Patient went back to Bahay Aruga to start a new cycle of
chemotherapy.
Medications currently taking are the following:
o Vincristine (unknown dosage)
o Tramadol 100 mg tablet for pain relief, taken only as needed.

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Group 2B Rhambdomyosarcoma

History of Present
Illness

(+) eye redness, blurring of vision; (-) headache,


purulent eye discharge, hearing difficulties, tinnitus,
epistaxis, sinusitis, sore throat, swallowing difficulties, dental
abnormalities, snoring, neck pain, swollen lymph nodes,
masses, neck stiffness

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Group 2B Rhambdomyosarcoma

Review of Systems
General:

(+) weight loss (2 kg in one week); (-) chills night sweats,


fever

Skin:

(-) jaundice, rashes, lumps, sores

Respiratory

(-) hemoptysis, dyspnea, cough, colds

Cardiovascular:

(-) cyanosis, edema, heart murmurs, chest pain, palpitations

Gastrointestinal: (+) nausea and vomiting, loss of appetite; (-) change in bowel
habits, colored stool, abdominal pain, hematemesis, melena,
hematochezia
Genitourinary:

(-) dysuria, dark urine, polydipsia, anuria, flank pain,

Musculoskeletal: (-) swelling of the legs, hematoma, lesions, tremors


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Group 2B Rhambdomyosarcoma

Maternal History

Born full term from a 35 years old G3P3 (3003) mother


o Midwife assisted Normal Spontaneous Delivery
Mother had no regular monthly prenatal check-up
She denied having any infections, smoking, drinking alcohol
and use of substances during and before pregnancy.
She took ferrous sulfate and multivitamins.

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Maternal History

Mothers
Age

GENDER

20

Female

G1
G2

35

Patient

G3

36

Male

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PLACE OF BIRTH

House
(Midwife
Assisted)

MODE OF
DELIVERY

OUTCOME/COMPLICATIONS

NSD

37 weeks; no complications

NSD

37 weeks; no
complications

NSD

37 weeks; no complications

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Birth History

Delivered via NSD


Active, had a good strong cry, able to breast feed with good
suck.
Urinate and pass meconium within 15 hours of birth.
No newborn screening and APGAR scoring done after birth.

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Feeding History

The patient was breast fed from birth until one


year old.
Complimentary solid food was introduced at six
months comprising of mashed rice and
vegetables.
At present, patient eats three times a day
comprising mostly of rice and vegetables.

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Developmental History

Started to walk alone at 10 months, write full name at the age of 2 and half years
and speak a full sentence by 2 years old.
HEADSSS:
o Home: Not close with his mother. Elder sister is his primary care giver.
o Education: Supposed to be in coming Second Year College where he is
taking up HRM. Attends class regularly and studies diligently. Have a good
relationship with classmates
o Eating Habits: Eats three times a day comprises of rice, meat and vegetables.
o After school and during weekends, patient used to hang out in his friends
house and they usually drink there almost two to three times every week. He
denies taking any illicit drugs.
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Developmental History

HEADSSS:
o Sexuality: Claims not to have any sexual relationship right now. First
and only sexual experience was at the age 16 years old with his first
girlfriend. Used condom as a mode of contraception and denies any
history of STDs.
o Suicidal Ideation: Denies any suicidal ideation even before being
diagnosed to have cancer.

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IMMUNIZATIONS:
o Had the following immunizations in the health center in

Polangui, Albay: BCG, DTwP, Hep B, Hib, MMR and OPV.


o Patients mother was not able to recall the number of doses
and when the patient took the immunizations
o No unusual reactions to the given vaccinations.

PAST ILLNESSES:
o No known illnesses in the past
o Never had measles, varicella, mumps and pertussis
o Never hospitalized
o No known surgeries, accidents and drug sensitivities.

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Family History

Father: Deceased (April 2014) - due to Liver


cancer
Mother: (+) Asthma, Hypertension; (-) Diabetes
Mellitus, CAD, Elevated cholesterol, Stroke,
Thyroid and Renal Disease, Cancer, Mental
Illness, Alcohol/Drug Addictions, Seizure Disorders
One sibling has asthma

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Personal and Social


History

Living with his parents and 2 siblings in a two bedroom house that is well ventilated
Denies smoking cigarette and illicit drug use
Used drink 3 500 ml bottle of redhorse 3 times per week but currently not drinking
any alcohol drinks.
Water source is from nawasa.
Food is prepared at home by eldest sister.
Garbage is thrown away twice a week
Mother works as a family maid.
Father is a smoker and drinks alcohol most of the time. He used to work as a family
driver.
Both parents deny taking illicit drugs.
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Physical Examination

General Survey: Patient is awake, active and not


in cardiorespiratory distress ambulatory.
Anthropometric:
o Height: 170 cm (CDC stature for age = above 5 th

percentile = normal)
o Weight: 49.1 kg (CDC age for weight = below 5 th
percentile)
o BMI = 16.98 = 17 = CDC BMI for age 0-20 boys = below
5th percentile = Underweight

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Physical Examination

Vital Signs
o Temperature: 36.6 C (afebrile)
o Pulse Rate: 72 beats/ mins (normal)
o Respiratory Rate: 16 breaths/ min (normal)
o Blood Pressure: 120/80 mmHg (normotensive)

SKIN: Skin is moist and warm to touch with good skin


turgor. Nail beds were pink and neither clubbing nor
koilonychias were observed.

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Physical Examination

HEENT
o Head: Scalp hair is equally distributed with light brown color.

Scalp is symmetrical and no lumps noted. Face is asymmetrical


on the zygomatic area due to a presence of a tender solid 4.5
cm width and 6 cm length bulge on left infraorbital area.
o Eyes:
Right Eye: Extraocular muscles are intact. Pupil is reactive to light.
Red orange reflex is present. No opacities and lesions were noted.
Visual acuity is 20/20. Pink palpebral conjunctiva, anicteric sclerae.
Left Eye: No perception to light. Globe of the eyes is
unrecognizable due to the presence of tumor.

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Physical Examination
o Ears:

Ears are symmetrical with no deformities. (-) External Canal for


lesions or serous fluid. Eardrums were not seen due to presence of
cerumen.
o Nose and Paranasal Sinuses:

Pink mucous membranes and midline nasal septum was noted. Left
maxillary sinus tenderness. (-) nasal discharge, bleeding, foreign
bodies, nasal flaring.
o Mouth and Throat:

Pink mucous membranes, lips, gums and buccal area. Uvula in


midline. (-) enlarged tonsils, exudates, vesicular or ulcerous lesion.
Presence on dental carries in the middle of upper front incisors. 2
right lower premolars, 2 upper left premolars and 1 upper left molar
were extracted,
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Physical Examination
o Neck:

(-) Limitation of motion, nuchal spasm or rigidity, masses or


swellings, neck mass, thyroid is mobile upon swallowing
and no enlargement noted.
o Lymph Nodes: No lymphadenopathy noted.

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Physical Examination

Chest and Lungs:


o Upon inspection, chest is symmetrical with no

deformities and chest retractions present.


o On palpation, symmetrical chest expansion was noted.
Both lung fields are symmetrically resonant upon
percussion. Vesicular on most of lung fields. Symmetrical
tacti fremitus.
o No rales, wheezes, periloquy, ergophony, tenderness,
nodules and lymphadenopathy noted.
o No palpable axillary lymph nodes noted.

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Physical Examination

Heart:
o Adynamic precordium, no visible pulsations.
o Regular heart rate and rhythm.
o Apex beat at 5th ICS MCL, S1> S2 at apex.
o (-) Murmurs, extra heart sounds, thrills and heaves,

pericardial friction rub

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Physical Examination

Abdomen:
o Abdomen is flat, symmetrical, and has normoactive

bowel sounds on all quadrants.


o No presence of visible pulsations, prominent vessels,
striae, scars and lesions. Umbilicus is inverted.
o Tympanitic upon percussion. No abdominal distension
and costovertebral angle tenderness.
o Negative Murphys, direct tenderness, rebound
tenderness and fluid wave. Liver span is normal (7.4
cm).

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Physical Examination

Genitourinary:
o No palpable inguinal lymph nodes.
o Both testes are descended. Penis is circumcised.
o Tanner stage: Both external genitalia stage and pubic hair is

Tanner stage 4..

Trunk and Spine: symmetrical and normal spinal


curvature.
Extremities:
o Full symmetrical pulses with rapid capillary refill, (-) clubbing,

cyanosis, nail abnormalities, palms and soles, edema,


hemorrhage, contusion, , pink nail beds
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Physical Examination

Cerebrum
o Mental State: Patient is oriented to person, place and time;

recent and remote memory intact

Cranial Nerves
o CN I Patient was able to smell coffee.
o CN II Right pupil reactive to light and accommodation; distinct

disc borders, no exudates, no hemorrhages. Left eye


undetermined.
o CN III, IV, VI Intact EOMs on the right eye. Left eye
undetermined.
o CN V - Good temporal and masseter muscle tone, pain and light
touch sensation felt bilaterally and symmetrically
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Physical Examination
o CN VII right and left facial movement intact
o CN VIII Webers Test: Rinnes Test: Bone conduction was

longer than air conduction.


o CNIX, X - uvula at midline; symmetrical soft palate
elevation
o CNXI - good sternocleidomastoid and trapezius muscle
tone, patient was able to shrug his shoulders
o CNXII - normal lingual articulation; tongue is in midline,
no atrophy and fasciculation

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Physical Examination

Motor:
o Normal and steady gait.
o Good muscle bulk and tone; full ROMs
o Motor Strength Right UE & LE = 5/5; Left UE & LE = 5/5

Cerebellar: Able to do the following properly:


finger to nose test, Romberg test, alternating
supination pronation test
Sensory: Sensation to touch, pain and
temperature is symmetrically intact.

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Physical Examination

Reflexes:
o Deep Tendon Reflexes: all ++ on both UE and LE (biceps

jerk, knee jerk and ankle jerk)


o Pathological Reflexes: (-) Babinski, Kernigs and
Brudzinski signs

Autonomic: Abnormal sweating, lacrimation,


salivation was not noted. Bladder and bowel
function is controlled.

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DIFFERENTIALS:
o Viral Conjunctivitis
o Orbital Lymphoma

DIAGNOSIS: Alveolar
Rhabdomyosarcoma (Stage 4)

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Discussion

Rhabdomyosarcoma

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