Transcript Pediatric Clinical Correlation Chronic Case

Pediatric Clinical Correlation
Chronic Case
Group 3
(Lim, Harold- Lipana, Kirk)
General Data
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Date of Admission: February 11, 2011
Name: Vitug, Junsen Barcas
Age: 16
Sex: M
Birthdate: December 24,1994
Address: Blk. 27, Lot 10, Palmera Spring II, Novaliches,
Caloocan City
Nationality: Filipino
Religion: Roman Catholic
Informant: Father and Patient
Reliability: 80%
Chief Complaint
“namamaga ang kanang hita”
( swelling of the right thigh )
History of Present Illness
• previously diagnosed with hemophilia A
• uncontrollable bleeding from a small wound
16 yrs. PTA • admitted and transfused with unrecalled units of Factor VIII
• Patient noted swelling of the of the right thigh
• Spontaneous; warm; Slight limitation of movement on affected
leg; (-) history of trauma
• Progression of swelling (whole thigh); bluish skin discoloration
• Patient’s mother noted a non-healing wound (lateral aspect of
the right thigh)
• oozing with foul smelling mixture of pus and bloody discharge
2 yrs. PTA
• accompanied by a low grade fever (Paracetamol 500mg/tab)–
resolved
• medicated wound with povidone iodine (Betadine) and dressed
with sterilized gauze
• Admitted for debridement
2 wksPTA
1 wk PTA
5 days PTA
• accidentally bumped right hip on the table
• pain was minimal and resolved
• no medications nor any consult done
• denied swelling or bruising immediately after the incident
• swelling on right hip with tenderness graded 8/10
• applied cold compress
• given paracetamol 500mg/tab , slight relief
• persistence of the pain and swelling
• stopped resolving with paracetamol
• Transfused with factor VIII and was advised admission; refused
• advised to follow up after a few days at OPD
• patient followed up at the OPD
• Swelling not resolving
Few hrs. PTA
• hence admission
• Immunization History
– Completed EPI from health center until 9 months of
age
• Past Medical History
– Primary complex(treated)- 6 months of HRZE
– Varicella- 9 years old
– Intracerebral hemorrhage: 2008 (factor VIII infusion);
resolved
• Family History:
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Hypertension -Grandparents
Hemophilia A – Both siblings
Brain tumor- Maternal grandmother
Prostate cancer- Maternal grandfather
Developmental/ Behavioral History
• Home: Second of 3 siblings, lives with his parents and brothers in Caloocan
• Education: currently 3rd year High School Student in Bagumbong High School in
Caloocan; average academic performance
• Eating Behavior: good appetite, no specific food preference, five basic food
groups present in daily meals
• Abuse: no reported sexual abuse or observed signs of physical abuse
• Activities: goes out with friends, stays home often
• Drugs: denies illicit drug use, non alcoholic beverage drinker, non smoker
• Sexual: denies sexual contact/activity; has not had romantic relationships
• Safety: wears seatbelt when riding cars; commutes often
• Suicidal ideations: no suicidal ideations/attempts
• Family: good interpersonal relationships with family members
• Image: good self esteem/desires opposite sex
• Recreation: goes to malls with family, use of internet, texts often
• Spiritual: regularly goes to Sunday mass
• Threats/Violence: no imposed harm to self or others; no reported threats
Socioeconomic/Environmental profile
• Patient lives in a 1-storey house with one
bedroom with his immediate family.
• Source of drinking water from a water station
and bathing water is from NAWASA.
• Garbage is collected once a week.
• The family owns a pet dog.
• Father is a smoker.
Review of Systems
General:
(+) anorexia; (-) fever; (-) easy fatigability
Skin:
see HPI
HEENT:
(-) eye pain, discharge; (-) deafness, tinnitus, aural discharge
occasional gum bleeding (-) neck stiffness; (-) sore throat
Cardiac:
(-) palpitations (-) syncope; (-) orthopnea; (-) cyanosis
Pulmonary:
(-) chest pain; (-) cough; (-) dyspnea
Gastrointestinal: (-) melena; (-) hematochezia; (-) constipation; (-) diarrhea; (-)
abdominal pain
Genitourinary:
(-) polyuria; (-) frequency; (-) hematuria; (-) dysuria
Musculoskeletal: (+) limitation in body movement; (-) joint pain; (-) joint swelling;
(-) bone pain
Vascular:
see HPI
Endocrine:
(-) polydipsia; (-) polyphagia; (-) polyuria; (-) heat/ cold intolerance
Neurologic:
(-) headache; (-) seizure; (-) hallucinations; (-) memory loss
Hematopoietic
(+) pallor; (+) easy bruisability
Physical Examination
General Survey
General appearance
alert, coherent, cooperative, calm, not in
cardiorespiratory distress, needs assistance when
getting out of bed, acutely ill
Body Habitus/ nutrition status undernourished, asthenic
Body Symmetry
Symmetrical
Personal Hygiene
Well groomed
Facies
No characteristic facies
Mood and affect
Appropriate, neutral
Vital Signs
Weight
36kg
Height
5'3 ft
BMI
14.1 (underweight)
Blood pressure
110/80mmhg
Pulse rate
96bpm
Respiratory rate
20 bpm
Temperature (axillary)
37.1o C
Skin
Inspection
Hair
Warm, no jaundice ,slightly pale complexion; no
skin turgor
Black, evenly distributed, smooth
Nails
No clubbing, symmetrical, pale nail beds
Mucosa
Pale palpebral conjunctiva, slightly pale oral
mucosa
LNs not enlarged
Palpation of lymph nodes
HEENT
Head
Ears
Symmetrical, no active lesions, no masses, no tenderness
pinna well curved, symmetric, in proportion with the head, not low set, no
preauricular tags, no watery, purulent, or bloody aural discharge, wet cerumen
along EAC; TM: intact, pearly white, positive cone of light, no effusion or bubbles,
no bulging, no peripheral erythema; mastoid: no masses, inflammation or
tenderness
Eyes
pale palpebral conjunctiva, anicteric sclera, (-) Hirschberg, Normal pupillary reflex
(direct and consensual), (+) Red orange reflex, visual acuity (20/30); cross cover
test- no eye movement observed on uncovered eye (L&R)
Nose
both nares patent, no alar flaring, no nasal discharge, septum not deviated, no
sinus tenderness, no masses within the nasal cavity, no pallor of the nasal
mucosa
Mouth & pink & dry lips, no gum bleeding or hypertrophy, no oral ulcers or vesicles
throat
tongue: moist, slightly pale; orophrayngeal mucosa: slightly pale, no thrush, no
ulcers; palate& uvula: symmetrical, no bulging, no cleft, uvula midline; teeth:
complete with minimal dental caries on 1 molar tooth (L)
tonsils: grade +1
Neck
Supple neck, trachea midline, no neck masses or nodules, no palpable lymph
nodes, neck veins not distended, no thyromegaly
Pulmonary
Inspection
Symmetrical chest expansion, no retraction, no use
of accessory muscles, no chest wall deformity, no
lesions, no clubbing and cyanosis
Palpation
Equal vocal and tactile fremiti on both lung fields, no
inflammation, no tenderness,
Resonant on all lung fields
Clear breath sounds, no crackles, no wheezing, no
egophony
Percussion
Auscultation
Lung Auscultogram
JVP
Carotid Pulse
Peripheral pulses
Precordium
Inspection
Palpation
Auscultation
Cardiovascular
3cm at 30o
Rapid upstroke, gradual downstroke
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Adynamic
No visible pulsation
5th LICS MCL, no heaves, thrills or lifts
S1<S2 apex; S1>S2 base; no murmurs
Heart Auscultogram
Inspiration
S1
Jugular venous
pulsation
Carotid artery
pulsation
Adynamic precordium
Apex beat: 5th LICS MCL
Apex: S1 is louder than S2
Base: S2 is louder than S1
No S3 or S4. No murmurs
No heaves, no thrills, no lifts
Expiration
S2
S1
S2