Transcript Group 1: RxMen

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Group 1: RxMen
Angustia ★ Ayes ★ Chan ★ Co
Garcia ★ Macapinlac ★Tumibay ★Vega
O Purpose of the presentation
O Impact of illness to the patient and
family
O Coping mechanism
O Family dynamics
O Social resources
General Data
O AP
O 4 mos./Male
O Filipino
O Roman Catholic
O Residing in San Miguel, Pasig City
O Informant: Mother, Father, and Paternal
Grandparents
O Reliability: 70%
O Admitted at PCGH on December 3, 2010
Chief Complaint
O Fever (2 days)
History of Present Illness
O 3 weeks PTA
O intermittent cough,
productive of whitish
phlegm
O No associated signs
and symptoms
O consult at a private
clinic
O Ambroxol (unrecalled
dosage)  No relief
O Amoxicillin 6.75 mg 
No relief
History of Present Illness
O 2 weeks PTA
O persistence of symptoms
O consult at a private clinic
O Carbocisteine
O Co-trimoxazole (unrecalled
dosage)
O Phenylpropanolamine
(Disudrin) 0.5 ml QID
O Phenylephrine HCl,
chlorphenamine (Neozep)
0.5 ml QID
O No relief
History of Present Illness
O 2 days PTA
O persistence of
O
O
O
O
symptoms
(+) undocumented
fever
(+) Difficulty of
breathing
No consult done
Parents self-medicated
patient with
Paracetamol drops
8.45 mg/kg/dose
History of Present Illness
O Morning PTA
O persistence of symptoms
O (+) rhinorrhea, productive
of yellowish-green mucous
O (+) vomiting milk and
phlegm (about 4 oz)
O Consult at health center
O Cephalexin 32.43 mg/kg/day
O Paracetamol 8.45
mg/kg/dose
O Increase in fever
O (+) cyanosis of distal
extremities
PCGH ER
Review of Systems
O Constitutional: no weight loss, no
O
O
O
O
weakness
Integument: (+) rashes (diaper), no
changes in color
Respiratory: no hemoptysis
Gastrointestinal: no changes in bowel
movement
Genitourinary: no frequency
Past Medical History
O no previous hospitalization
O no previous operations
O no history of trauma
Family Medical History
O Liver disease, Tuberculosis - Maternal
O
O
O
O
side
Breast cancer - Paternal side
(-) Asthma
(-) DM
(-) Hypertension, cardiac disease
Developmental History
O patient is a 4 mo., male
O (+) grasps object placed in hand
O (+) moves head toward sound
O (+) reaches for objects
O (+) chews
O (+) roll over
O (-) chest up, arm support
Immunization History
O BCG - 1 dose
O OPV - 1 dose
O Hepa B - 1 dose
O No HiB
Birth History
O Born Full Term to a 17 year old G1P1,
delivered via Normal Spontaneous
Delivery with birth weight 3.6 kg, at a
lying-in clinic, attended by midwife, (-)
perinatal/neonatal complications
Nutritional History
O Breast fed for 2 weeks then shifted to
milk formula (8 oz. per feeding x 4
feedings a day)
O No known food allergy
Genogram (12/30/10)
I
48
43
49
46
II
18
24
21
20
16
15
14
13
11
18
III
4 mos.
Personal Social history
O Only Child
O Mother - 18 y/o
not employed
O Father - 20 y/o
factory worker
O Parents not married
O Families are not on good terms
Environmental history
O Patient does not stay permanently in one
household. He is shuttled from the
mother’s household to the father’s
household and vice versa
O Lives in a 1 story wooden house near the
streets with 2 bedrooms.
O The house is well ventilated and well
lighted.
Environmental history
O Their water supply comes from Manila
Waters.
O Drinking water of the patient was
previously Wilkins, but now the water
comes from a refill station
O Garbage is collected every day.
Physical Examination
O General Survey:
O Conscious, alert, in mild respiratory distress,
well-nourished
O Vital signs:
O HR 165, RR 38, Temp 40.5oC
O Anthropometrics:
O Length 59 cm (<3rd percentile)
O weight 7.4 kg (50-85th percentile for age,
>97th percentile for length)
O HC 40.5 cm (15th percentile), CC 44.3 cm, AC
46.4 cm
O Skin:
Physical Examination
O normal skin color, good turgor (CRT<2 sec), flushed skin
O (+) diaper rash, inguinal area extending to buttocks, (-) lesions,
flushed skin
O HEENT and neck:
flat, open anterior fontanel; closed posterior fontanel
Normal hair distribution, (-) masses/depressions
anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm ERTL
(-) ear deformities, (-) discharge, (+) intact tympanic membrane, (+)
cone of light
O (-) nasal deformities, (+) rhinorrhea, yellow-green discharge
slightly dried
O (-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy,
supple neck, flat neck veins
O
O
O
O
Physical Examination
O Heart:
O adynamic precordium, apex beat at 5th
ICS LMCL, tachycardic, regular rhythm
O (-) murmurs, good S1/S2
O Lungs:
O (-) scars or masses, (+)
intercostal/subcostal retractions
O symmetric chest expansion, resonant on
percussion, (+) rhonchi lower lung fields,
(+) crackles on bilateral lower lung fields
Physical Examination
O Abdomen:
O globular abdomen, (-) masses or scars
O Normoactive bowel sounds
O tympanitic abdomen
O (-) tenderness, (-) organomegaly
O Genital exam:
O grossly male, (-) deformities
O Descended testes
Physical Examination
O Extremities:
O full and equal pulses, (-) edema, (-)
cyanosis
Neurologic Examination
O Cranial Nerves:
O
O
O
O
O
O
O
O
O
CN I - not tested
CN II – 3-4 mm equally reactive to light
CN III, IV, VI – intact EOMs
CN V – reacts to facial sensory stimulation
CN VII – no facial asymmetry, able to smile and
cry
CN VIII – responds to sound and verbal stimuli
CN IX, X – able to feed, good suck
CN XI – able to turn head from side to side
CN XII – tongue midline
Neurologic Examination
O Sensory: responds to stimuli (light touch)
O Motor: good muscle tone and strength
O Reflexes
O (+) Babinski
O (+) palmar grasp
O (-) rooting
O (-) moro
O (-) tonic neck
Salient Features
O 4 mo./M
O fever (2 days) associated with cough and
colds, difficulty of breathing, peripheral
cyanosis, and vomiting
O medications given afforded no relief
O on PE, (+) tachycardia, (+) intercostal
retractions, (+) rhinorrhea, (+) rhonchi
on lower lung fields, (+) crackles on
lower lung fields
Admitting Diagnosis
O Pediatric Community Acquired
Pneumonia, Category C
O (+) fever, difficulty of breathing, cyanosis,
cough and colds
O PLUS findings on PE: (+) tachycardia, (+)
intercostal/subcostal retractions,(+)
rhinorrhea, (+) rhonchi, (+) crackles