??? Group 1: RxMen Angustia ★ Ayes ★ Chan ★ Co Garcia ★ Macapinlac ★Tumibay ★Vega

INTRODUCTION

Introduction Purpose of the presentation Impact of illness to the patient and family Coping mechanism Family dynamics Social resources

General Data AP 4 mos./Male Filipino Roman Catholic Residing in San Miguel, Pasig City Informant: Mother, Father, and Paternal Grandparents Reliability: 70% Admitted at PCGH on December 3, 2010

Chief Complaint Fever (2 days)

History of Present Illness 3 weeks PTA intermittent cough, productive of whitish phlegm No associated signs and symptoms consult at a private clinic Ambroxol (unrecalled dosage)  No relief Amoxicillin 6.75 mg  No relief

History of Present Illness 2 weeks PTA persistence of symptoms consult at a private clinic Carbocisteine Co-trimoxazole (unrecalled dosage) Phenylpropanolamine (Disudrin) 0.5 ml QID Phenylephrine HCl, chlorphenamine (Neozep) 0.5 ml QID No relief Carbocisteine (50 mg/ml) Co-trimoxazole (8-10 mg/kg/day divided in 2 doses for trimethoprim; 40-60 mg/kg/day in 2 divided doses of sulfamethoxazole) Phenylpropanolamine 6.25 mg/ml (Disudrin) 0.5 ml QID Phenylephrine HCl 6.25 mg/ml, chlorphenamine maleate 0.5 mg/ml (Neozep) 0.5 ml QID

History of Present Illness 2 days PTA persistence of symptoms (+) undocumented fever (+) Difficulty of breathing No consult done Parents self-medicated patient with Paracetamol drops 8.45 mg/kg/dose Paracetamol drops (10 mg/kg/dose)

History of Present Illness Morning PTA persistence of symptoms (+) rhinorrhea, productive of yellowish-green mucous (+) vomiting milk and phlegm (about 4 oz) Consult at health center Cephalexin 32.43 mg/kg/day Paracetamol 8.45 mg/kg/dose Increase in fever (+) cyanosis of distal extremities Cephalexin (25-50 mg/kg/day) Paracetamol (10 mg/kg/dose) PCGH ER

Review of Systems Constitutional: no weight loss, no weakness Integument: (+) rashes (diaper), no changes in color Respiratory: no hemoptysis Gastrointestinal: no changes in bowel movement Genitourinary: no frequency

Past Medical History no previous hospitalization no previous operations no history of trauma

Family Medical History Liver disease, Tuberculosis - Maternal side Breast cancer - Paternal side (-) Asthma (-) DM (-) Hypertension, cardiac disease

Developmental History patient is a 4 mo., male (+) grasps object placed in hand (+) moves head toward sound (+) reaches for objects (+) chews (+) roll over (-) chest up, arm support

Immunization History BCG - 1 dose OPV - 1 dose Hepa B - 1 dose No HiB

Birth History 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 Breast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day) No known food allergy

Genogram (12/30/10) I 49 43 48 46 II 24 18 21 16 15 14 13 11 20 18 III 4 mos.

Personal Social history Only Child Mother - 18 y/o not employed Father - 20 y/o factory worker Parents not married Families are not on good terms

Environmental history Patient does not stay permanently in one household. He is shuttled from the mother’s household to the father’s household and vice versa Lives in a 1 story wooden house near the streets with 2 bedrooms. The house is well ventilated and well lighted.

Environmental history Their water supply comes from Manila Waters. Drinking water of the patient was previously Wilkins, but now the water comes from a refill station Garbage is collected every day.

Physical Examination General Survey: Vital signs: Anthropometrics: Conscious, alert, in mild respiratory distress, well-nourished Vital signs: HR 165, RR 38, Temp 40.5oC Anthropometrics: Length 59 cm (<3rd percentile) weight 7.4 kg (50-85th percentile for age, >97th percentile for length) HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm

Physical Examination Skin: HEENT and neck: normal skin color, good turgor (CRT<2 sec), flushed skin (+) diaper rash, inguinal area extending to buttocks, (-) lesions, flushed skin 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 (-) nasal deformities, (+) rhinorrhea, yellow-green discharge slightly dried (-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy, supple neck, flat neck veins

Physical Examination Heart: Lungs: adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm (-) murmurs, good S1/S2 Lungs: (-) scars or masses, (+) intercostal/subcostal retractions symmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields

Physical Examination Abdomen: Genital exam: globular abdomen, (-) masses or scars Normoactive bowel sounds tympanitic abdomen (-) tenderness, (-) organomegaly Genital exam: grossly male, (-) deformities Descended testes

Physical Examination Extremities: full and equal pulses, (-) edema, (-) cyanosis

Neurologic Examination Cranial Nerves: 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 Sensory: responds to stimuli (light touch) Motor: good muscle tone and strength Reflexes (+) Babinski (+) palmar grasp (-) rooting (-) moro (-) tonic neck

Salient Features 4 mo./M fever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomiting medications given afforded no relief on PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields

Admitting Diagnosis Pediatric Community Acquired Pneumonia, Category C (+) fever, difficulty of breathing, cyanosis, cough and colds PLUS findings on PE: (+) tachycardia, (+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles