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

2. INTRODUCTION

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

4. 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

5. Chief Complaint
Fever (2 days)

6. 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

7. 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; 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

8. 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)

9. 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 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

10. 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

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

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

13. 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

14. Immunization History
BCG dose
OPV dose
Hepa B dose
No HiB

15. 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

16. 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

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

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

19. 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.

20. 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.

21. 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

22. 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

23. 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

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

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

26. 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

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

28. 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

29. 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