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Oquendo, Trisha Pamela P.

January 25,
2017
COM III B Group 10 Block XVIII
precept 2

Hematology Pediatric Preceptorial

GENERAL DATA

Informant: Jenalyn Bedonia


Relationship: Mother
Reliability: 90%
Date/s of interview: January 23 & 24, 2017
Time of interview: 1:00-2:30 pm & 3:00-4:00 pm

Name of Patient: Jenesis Bedonia


Age: 2 months and 14 days
Sex: Male
Date of birth: November 10, 2016
Place of birth: Home delivery, San Rafael, Lemery, Iloilo
Address: San Rafael, Lemery, Iloilo
Nationality: Filipino
Religion: Roman Catholic
Date of admission: January 10, 2017
Time of admission: 9:00 am
Ward: PSW - A
No. of admissions: 1

CHIEF COMPLAINT
Rapid breathing (increased respiratory rate)

HISTORY OF PRESENT ILLNESS

7 days prior to admission, patients paternal uncle, an albularyo, subjected


the patient to a ritual to drive evil spirits away which ncluded burning of
different kinds of leaves and the patient was exposed to the smoke and
fumes of the burning leaves for 15 minutes. The ritual was done for 7
consecutive nights, and according to the mother, patient started coughing
after the first night of the ritual, but no treatment was done.

6 days prior to admission, patient still had dry cough even without exposure
to smoke with concurrent clear and watery nasal discharge. No treatment or
consultation done. Coughing exacerbated with exposure to the smoke.

1 day prior to admission, dry cough and nasal catarrh progressed, no


treatment or consultation done. Patient had undocumented fever that night
and mother gave 0.3 ml drop of paracetamol with no relief. Mother noticed
dryness of the lips, and retractions of the intercostal space and
supraclavicular areas when breathing. Mother also noticed patient breathing
through his mouth. Patient became irritable with shrill cry during the night
and was not able to sleep. He also stopped breastfeeding by midnight. No
other treatment done.

Few hours prior to admission, patient had one episode of watery, blackish
stool. Patient was still irritable with shrill cry, feverish, and not breastfeeding.
Retractions of intercostal and supraclavicular spaces are still evident.
Difficulty of breathing worsened and mother described it as daw ginalagas
iya ginhawa by breathing through his mouth, thus this admission to WVSU
MC on January 10, 2017 at 9:00 am.

Pertinent Negatives:
Nasal flaring, chills, wheezing, stridor, grunting

PERSONAL HISTORY

Prenatal History
Mother started her regular prenatal check-ups at 4 months of gestation. She
took ferrous sulfate for maintenance. She has no history of smoking or
alcohol intake during pregnancy, but the husband is a smoker and mother is
continually exposed to second-hand smoking. No history of infection and drug
intake during pregnancy. She experienced cough on the 6 th month of
gestation but was resolved by drinking oregano leaves extract. Mothers
immunizations are all updated. Mothers daily activities included pumping
and fetching water from a nearby water pump and doing laundry. Her diet
was mainly fruits, shellfish, and seaweed.

Natal History
Patient was born to a G5P5 (5,0,0,5) mother, NSVD, cephalic presentation, no
hemorrhage or complications. She was in labor for 9 hours and was assisted
by a midwife while giving birth at home. She was then brought to an in-lying
clinic at Lemery after giving birth.

Neonatal History
Patient had good cry, was pinkish in color, with no congenital deformities.
Breastfeeding was immediately initiated with good suck. Birth weight was 3.3
kilograms. Patient was full term, as claimed by mother. Took approximately 4
oz of milk per feeding. New Born Screening was not done.

Developmental stages
Age Gross Motor Fine Motor and Hearing and Social Behavior
Vision Speech
(cognitive) (language)

Startle by Sleep most of


Able to suck
Newbor sudden sound, the time, stops
and swallow
n cries for when crying when held
milk, head lag
hungry and rock

One Able to raise Stares at bright Cries when Sleeps most of


hungry, wet the time, stops
head slightly objects like lamps,
month diaper crying when held
hands fisted
or spoken to

Able to lift Hands fisted, grasp


Starts cooing
Two head slightly, finger placed in his Smiles and
when spoken
months can turn head hand, follows laughs
to
left or right moving object
PAST MEDICAL HISTORY
Patient was previously admitted to Western Visayas Medical Center last
December 3 22, 2016 due to pneumonia and was well at discharge. She
was prescribed with Ferrous Sulfate 0.3ml drops OD for 3 months. She also
takes tiki tiki multivitamins 0.3ml drops OD.

IMMUNIZATIONS
1st dose DPT
1st dose Hepatits B
1st dose PCV
No BGC given
No OPV given

FAMILY HISTORY
Patients maternal grandmother is alive and is diagnosed with DM, asthma,
and arthritis. Patients paternal grandmother died of stroke, maternal
grandfather died of an unrecalled cause with history of blindness. Patients
father is a diagnosed hypertensive. Maternal aunt has asthma. Patient has 4
siblings, all are apparently well except for his 2 nd sibling, his sister, who had
history of blackening of fingernails and toenails due to vitamin deficiency.

No family history of cancer, noticeable pallor, TB, other respiratory diseases,


and cardiac diseases.

SOCIAL AND ENVIRONMENTAL HISTORY


Patient lives with his parents and 3 siblings. One sibling was adopted out due
to financial constraints. His father, 57 years old with a high school level
education, is the main provider for the family and works as a farmer. His
mother, 34 years old, also with a high school level education, is the one that
takes care of the children and their home. They have been married since
December 18, 2008.

They live in a house far from the main road, with a difficulty in accessing
public transportation, and they burn their garbage near their house. They
have different animals around their house such as goats, carabaos, dogs, and
free-range chickens.

Patient is purely breast-fed with baby-led feeding since birth except when he
was hospitalized last December, wherein he was required to be mixed fed
with bona and breast milk. Currently, patient is also mixed-fed at least 15
bottles of 4-2 ounces of Alacta powder milk, 1:1 preparation, if not feeding
from mother. Breast feeding at night approximately 3 times, with good suck.

PHYSICAL EXAMINATION

GENERAL SURVEY: Patient is awake and active, irritable, and in


cardiopulmonary distress.

VITAL SIGNS
Temperature: 36.7oC (N = 36.37 38oC)
Pulse rate: 67 bpm
Heart rate: 95 bpm (N= 100-150 bpm) Bradycardic
Respirations: 64 cpm (N = 35-55 cpm) Tachypneic
O2 saturation: 98% (N = 95-99%)

ANTHROPOMETRIC MEASUREMENTS
Length: 57 cm
Weight: 4.4 kg
BMI:
Head Circumference: 40 cm
Chest Circumference: 41 cm
Abdominal Girth: 42 cm

PHYSICAL ASSESSMENT
Integumentary
Patients skin is generally brown with good skin turgor and capillary refill of
<2s. Bluish discoloration on the proximal part of the left upper extremity. No
simian crease noted.

HEENT
Closed posterior fontanel, open anterior fontanel. No cranial masses or
lesions noted. Evenly distributed thin black hair. Pupils reactive to light, 4mm,
with pale conjunctiva, no hypertelorism noted. Ears with easy recoil, and in
line with the outer canthus of the eyes. Nose at midline, patent nares, no
nasal discharges noted, and size of nose symmetrical with the face. Pale and
dry lips, pale buccal mucosa, negative macroglossia. No palpable cervical,
supraclavicular, and aurical lymph nodes noted.

Chest & Lungs


Chest is circular and intact, symmetrical clavicles and scapula. Sternum is
positioned at midline. Abdominal breathing noted, with periodic breathing
with a pause of <5 sec. No gross chest deformities noted. Supraclavicular,
suprasternal and subcostal retractions noted, but no use of accessory
muscles of respiration. Symmetrical chest expansion, tactile fremitus is
symmetrical, and chest is hyperresonant upon percussion. Broncho-vesicular
breath sounds noted on upper and mid lung fields and vesicular breath
sounds noted on most lung portions.

Cardiovascular
PMI at 4th ICS left MCL with sdynamic precordium. Cardiac rate at 95 bpm.
Capillary refill <2 sec. Peripheral pulses palpable on brachial and femoral
areas. Heart sounds have regular rate and rhythym with distinct S1 and S2,
no murmurs noted.

Breast & Axilla


Nipples inverted without discharge. No lumps, masses, discoloration noted on
breasts. No palpable axillary lymph nodes noted.

Abdomen
umbilicus is at midline, no visible lesions noted. Normoactive bowel sounds,
no masses palpated. Liver edge at 2 cm below right costal margin MCL.

Genitalia
Grossly male with descended testis, tanner stage 1. No palpable inguinal
lymph nodes, no herniation.

Anus & Rectum


Patent anus. DRE not done.

Musculockeletal
No visible deformities noted. Spine at midline.

CRANIAL NERVE EXAM

CN I not tested
CN II Able to track objects and faces
CN III, IV, VI Able to track objects and faces
CN V Positive rooting, and sucking reflex
CN VII Symmetric facial features
CN VIII Not tested
CN IX, X Able to swallow
CN XI Symmetrical shoulders
CN XII Coordinated sucking

MOTOR & SENSORY EXAM


Patient has normal muscle tone and cries after a painful stimulus.

REFLEXES
Babinski, grasp, moro, sucking, rooting, plantar and palmar grasp, tonic neck
reflex present

DIFFERENTIAL DIAGNOSIS
Diagnosis Pertinent Positives Rule out because
Asthmatic History of smoke/fume Negative wheezing
Attack exposure due to the familys Bradycardic
(Cough belief in rituals
variant History of exposure to
asthma) - environmental allergens (e.g.
doesnt have
classic cattle, chickens, dogs, burning
asthma of garbage near the house)
symptoms of Continuous nonproductive
wheezing and cough
shortness of Shortness of breath
breath. CVA Increased respiratory rate
is
Loss of appetite
characterized
Intercostal and
by a
persistent, supraclavicular retractions
dry cough. Agitation, manifested by the
crying
Bronchiolitis Cough Negative wheezing
Rhinitis manifested by nasal No exposure to an
catarrh older contact with
Undocumented fever minor respiratory
syndrome within the
previous week of
admission.
Community Fever Negative rales
Acquired Cough No increase in tactile
Pneumonia Tachypnea fremitus
Nonproductive cough

LABORATORY WORK-UP
Complete blood count with differential counting and platelet
Chest X-ray
Allergy testing

WORKING DIAGNOSIS
Severe difficulty of breathing secondary to asthmatic attack, with anemia.

PROPOSED TREATMENT
Correction of significant hypoxemia with supplemental oxygen
Inhaled beta2-agonist for the rapid reversal of airflow obstruction with
repeated or continuous administration.
Short course of systemic corticosteroids