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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