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GENERAL DATA

Px IFI 1 1/12 year old, infant, female Roman Catholic DOB: Feb 18, 2011- Pines City Hospital Current address: Evangelista St. Baguio City 2nd admission, dated March 31, 2012. Informant: Mother; 90% reliability.

CHIEF COMPLAINT

Fever & Rapid deep breathing

HISTORY OF PRESENT ILLNESS

Patient apparently well, until 1 day PTA. Presented with fever (39.5c), as noted by the mother Self prescribed: Paracetamol (Tempra)
1 mL, every 8 hours ED 10-20 mkd q4, CD 168mg per dos??

Hx of Swimming the previous day. No cough, no LBM, no abdominal pain with fair oral intake. Few hours PTA: sought consult with private physician and was advised admission Adviced chest x-ray and urinalysis.

PAST PERSONAL HISTORY

BIRTH HISTORY: PRENATAL


HISTORY
Mother: 28 y/o G1P0 (0-0-0-0) Cognizant of pregnancy at 7 weeks AOG

amenorrhea

from a previously regular menstrual cycle confirmed by pregnancy test done at 7 weeks.

Prenatal care
instituted at 7 weeks AOG by Obstetrician. Total, 9 prenatal check ups, regularly Ultrasound (7weeks AOG)

Single, alive fetus.

No exposure to VED/smoking/alcohol/radiation

NATAL HISTORY

Pt. born via NSVD: full- term


(Pines

City Hospital)

BW= 3.43 kg; BL unrecalled. Pink body, Good cry, Active limb movements upon birth. NO congenital malformations NO resuscitative measures done.

NEONATAL HISTORY

Breastfed:good suck 2 days hospital stay Umbilical stump fell of after 9 days

No

signs of infection.

Newborn screening done and results were NORMAL

FEEDING HISTORY

Pure breast feed till 2 month old Onwards: Combination feeding


q

2 hours first 6 months per demand 6 months to present

Presently: 4 (8 oz) bottle/day (Gain)


Dilution

of 3 scoops per 180ml

Semi solid foods were introduced at 7 months.

FEEDING HISTORY

Sample diet:

BREAKFAST 1 bowl of Wheat Milk Banana Cerelac LUNCH DINNER SNACK


cup rice, 1 piece meat, vegetables

cup rice, 1 piece meat, vegetables

Fruits: banana, papaya, cereals

Multivitamins (Appebon)
Started

at 1 1/12 y/o at 6 mos old.

Vitamin C (Ceelin)
Started

GROWTH AND DEVELOMPENTAL HISTORY: Physical Growth


AT BIRTH PRESENTLY

BW= 3.43 Kg BL= unrecalled


HC= unrecalled CC= unrecalled AC=

Weight=8.4 kg Length= 68 cm

Developmental Milestones
Motor Adaptive Walks with support Can stand independently Picks up small objects with unassisted pincer movement releases object to other person on request A few words besides "mama," papa" Plays simple ball game Helps in dressing

Language Social

Patient sleeps at 8pm in the evening and wakes up at 6am in the morning. Sleep is interrupted when the patient is hungry. She is not toilet trained. She interacts with family and peers without discipline problems. THE PATIENTS PHYSICAL, COGNITIVE, SOCIAL, AND EMOTIONAL DEVELOPMENT IS AT PAR FOR AGE

Immunizations
Vaccine BCG DPT OPV IPV HepB Measles MMR HiB Influenza Pneumococcal Rotavirus Meningococcal HepA Varicella Typhoid Others Provenar Pentaxin / / / / Fever / / / / Fever / Fever 1st Dose / / / / / / / Fever Fever 2nd Dose 3rd Dose Booster Place Reactions

Past Medical History

Previous hospitalization:
May

2011:

PCAP:

unrecalled doses of Salbutamol, Cefuroxime, and Paracetamol.

No reported childhood illnesses. No known allergies to food and drugs. No current medication is being taken.

SOCIAL AND ENVIRONMENTAL HISTORY

Father- 30 years old Network Engineer, college graduate Mother is 29 years old, housewife, college graduate. Primary caregiver is the mother.

Non-congested neighbourhood in a 2 storey house and they live in 1 room with 6 occupants. Source of water for domestic purposes comes from BWD. Drinking water is from water delivery station. 1 pet dog Garbage is segregated and collected regularly. Toilet is flushed type. Hand washing practices is frequently done before meals.

FAMILY HISTORY

Patient is the first child. Both parents apparently well. Family history of bronchial asthma, hypertension, and stroke; No history of cancer, arthritis, CAD, and DM.

REVIEW OF SYSTEMS

GENERAL: (-) weight loss, (+) febrile episodes, (-) no chills, (-) sweats, (+) incessant crying, (+) irritability, poor oral intake, (-) lethargy SKIN: (-) cyanosis, (-) pallor, (-) lesions, (-) dryness, (-) rash, (-) itching, (-) moles, (-) sores, (-) hives, (-) pigmentations, (-) yellowish discolorations HEAD AND NECK: (-) lesions, (-) trauma, (-) swelling, (-) headache, (-) pain, (-) stiffness EYES: (-) tearing, (-) itching, (-) redness, (-) discharge, (-) pain, (-) diplopia, (-) dryness, (-) infection EARS: (-) discharges, (-) pain, (-) tinnitus, (-) vertigo, (-) hearing loss NOSE: (-) dryness, (-) congestion, (-) colds, (-) sneezing, (-) pain, (-) obstruction, (-) bleeding MOUTH AND THROAT: (-) soreness, (-) pain, (-) infection, (-) ulcers, (-) hoarseness, (-) dryness, (-) gum bleeding, (-) dental caries, (-) tongue lesions, (-) swallowing problems RESPIRATORY: (-) cough, (-) sputum, (-) pain, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) TB/PKI

CARDIAC: (-) edema, (-) cyanosis, (-) palpitations, (-) murmur, (-) known CHD, (-) rheumatic fever GASTROINTESTINAL TRACT: (+) poor appetite, (+) anorexia, (-) abdominal pain, (-) vomiting, (-) nausea, (-) diarrhea, (-) constipation, (-) flatulence, (-) melena, (-) hematochezia, (-) change in bowel habits, (-) hernia, (-) use of laxatives or antacids, (-) jaundice, (-) hepatitis URINARY AND RENAL: (-) dysuria, (-) hematuria, (-) nocturia, (-) incontinence, (-) frequency, (-) stones, (-) infections GENITALIA: (-) pain, (-) swelling, (-) discharge, (-) tenderness, (-) malignancy MUSCULOSKELETAL: (-) deformities, (-) pain, (-) swelling, (-) tenderness, (-) cramps, (-) weakness, (-) trauma, (-) sprains, (-) fractures, (-) stiffness, () backache ENDOCRINE AND METABOLIC: (-) polydipsia, (-) polyphagia, (-) hair change, (-) weight change, (-) temperature intolerance HEMATOLOGIC: (-) anemia, (-) bleeding, (-) bruising, (-) transfusions, (-) malignancy NERVOUS SYSTEM: (-) syncope, (-) dizziness, (-) seizures, (-) convulsions, (-) tremors, (-) coordination problem, (-) sensory disturbance, (-) pain, (-) motor problems, (-) memory problems

PHYSICAL EXAMINATION:

General Survey: The patient is awake, alert, irritable, not in respiratory distress. Vital Signs:

CR: 130 bpm (N:80-130) normal RR: 36 bpm (N: 20-30) Tachypnic T: 37.2 C Afebrile

Anthropometric measurements:

Weight: 8.4kg Height: 68 cm Z-score: 1 (normal)

Skin: The skin is not jaundice, no pallor, no cyanosis, no rashes, and no pigmentations. The skin is soft, smooth and warm to touch, no dryness and with good skin turgor. HEENT:

Head and Neck: Head symmetrical, round, normal hair distribution, no scars, no gross deformities, no parasites, no lesions present and no tenderness. Neck has no deformities, no lesions, no swelling, no supraclavicular and suprasternal retractions, no neck vein engorgements, no cervical LAD, and no tenderness. Eyes: Non-sunken eyeballs, anicteric sclerae, no opacities, pinkish palpebral conjunctiva, no discharges, no swelling and pupils 2-3 mm ERTL. Ears: Normally set ears, external ear is same color with the skin, no discharges, no lesions, no swelling and with intact tympanic membrane. Nose: No alar flaring, no nasal discharges, no congestion, no lesions, Mouth: Moist lips and buccal mucosa, no circumoral cyanosis,

Chest and Lungs: With symmetrical lung expansion, no lagging, no retractions, (+) crackles (-) wheeze (-) ronchi Heart: Adynamic precordium, regular rhythm, PMI is located at 5th ICS left MCL. No murmurs, no bruit, normal rate and regular rhythm. Back: Vertebra is located in midline, no visible deformities, and no lesions. Abdomen: Globular, non-distended, inverted umbilicus, regular in contour, normoactive bowel sounds, soft, tympanitic, (-) tenderness,
(-) organomegaly

Genitalia: Grossly female Anus and Rectum: Not assessed Extremities: No cyanosis, no edema, no lesions and no deformities. Normal configuration of nails and palmar crease. Skin temperature is appropriate, symmetrical pulses on both upper and lower extremities, and good capillary refill.

Neurologic examination:

Cerebrum: awake, no changes in sensorium Cerebellum: (-) tremors, (-) nystagmus, (-) ataxia Cranial Nerves: CN I not assessed CN II can see mother and cries upon seeing junior intern CN II, III papillary light reflex: 2-3mm ERTL CN III, IV, VI (+) intact extraocular muscle movement CN V not assessed CN VII symmetrical nasolabial folds CN VIII reactive to noise CN IX, X able to swallow, (+) gag reflex CN XI can shrug shoulders CN XII no tongue deviation, it is located at the midline Motor system: no seizure, no flaccidity, no atrophy, good muscle tone, Sensory system: respond to touch and stimuli Reflexes: not assessed Meningeal status: (-) kernigs and bruzidski signs

END

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