History of Present Illness -(+) fever (undocumented) -(+) sorethroat -(+) rashes (red, pruritic patches?) -no cough and colds -Consult at local clinic and diagnosed with tonsillopharyngitis -Given Co-amoxiclav (unrecalled dosage) until lysis of fever (4 days) 18 days PTA
History of Present Illness -Facial and periorbital edema -Abdominal enlargement -Difficulty of breathing -Tea-colored urine -↓ urine output -no edema of extremities -No medications taken -No consultation done 3 days PTA
History of Present Illness -Consult at a local clinic -Urinalysis, BUN, Creatinine, ESR -Persistence of symptoms 2 days PTA Admission 1 day PTA
Feeding History Picky eater, dislikes vegetables ACI 24 hour food recall – Breakfast: 1 cup soup, 1 glass milk – Lunch: ½ cup rice, 1 pc chicken breast – Dinner: ½ cup rice, 1 pc chicken breast, mango – Snack: 1 cup noodles with egg
Personal History Developmental history – hops on one foot – Copies a drawing of a cross and circle – Counts to ten – Plays cooperatively – Goes to the toilet alone
Past Illnesses (+) bronchopneumonia (2006) (+) mumps (unrecalled date) (-) surgeries or blood transfusions (-) known allergies (-) asthma
Immunization History BCG Hep B x 3 doses DTP x 3 doses OPV x 3 doses Measles BOOSTER DOSE?? At a local health center in Quezon City
Family History (+) HPN – father (-) Renal disease (-) DM (-) PTB (-) Asthma (-) CA
Family History NameAgeOccupationEducational attainment Health Agnes Aguba (mother) 29Vegetable stand owner HS graduateHealthy Gerald Alperto (father) 30Tricycle driver3 rd yr collegeHealthy Wendell Alperto (sibling) 1 yr 4 mos. / Male -- Healthy
Socioeconomic and Environmental History Lives with parents and younger sibling in a 1- floor, cemented apartment like complex. Well-lit but not well-ventilated (no windows, 1 door) 2x/week garbage collection with no segregation There are no factories nearby, but there is exposure to vehicular exhaust Purified drinking water No pets
PE on Admission General Description: Patient is awake, coherent, ambulatory, not in cardiorespiratory distress, well-nourished, and well-hydrated. Vital Signs: pulse rate 120 beats/min; respiratory rate 36 cycles/min; temperature 36.5° C; blood pressure 110/70 mm Hg. Anthropometric Measurements: wt 17 kg (z score below 0), ht 104 cm (z score below 0), AC: 52.5cm. Skin: warm and moist, (-) jaundice, (-) edema, (-) loss of tissue turgor. Head, Eyes, Ears, Nose: (-) swelling, (-) discharge, tympanic membrane intact, pink, flat, cone of light present, (-) effusion; nasal septum midline, (-) sinus tenderness, (+) facial edema, (+) impacted cerumen. Mouth and Throat: moist buccal mucosa, pink lips, (-) dryness, (-) gum bleeding; tongue pink, (-) dryness, non -hyperemic posterior pharyngeal area, grade 3 tonsillar enlargement, (-) exudates. Neck: supple neck, (-) palpable cervical lymph nodes.
PE on Admission Lungs: symmetrical chest expansions, normal vocal fremiti, lung fields resonant on percussion, decrease breath sounds on anterior chest, fine crackles on the right base of lung, and occasional wheezes. Heart: dynamic precordium, (-) thrills, (-) heaves, apex beat 4 th LICS MCL, S 1 louder than S 2 at the apex, S 2 louder than S 1 at the base, S 2 splits on inspiration, (-) murmurs, Abdomen: globular, soft, nontender (-) prominent vessels, (-) striae, (-) pulsations, (-) paradoxic movements with respect to respiration, normoactive bowel sounds (10/min), (-) splenomegaly, (+) costovertebral angle tenderness, (+) fluid wave, (+) shifting dullness, (+) umbilical hernia. Extremities: (-) pain, (-) swelling, (-) clubbing. Spine: (-) scoliosis, (-) tenderness.
Neurologic Examination Conscious, coherent, follows commands, GCS15 Cranial nerves intact: Pupil size 2-3 mm equally reactive to light; no ptosis (OU) intact EOM movements, can move face and shrug shoulders side by side. No abnormal movements, normal gait MMT 5/5 on all extremity, DTR (++) on all extremities No sensory deficit No involuntary movement, no spasticity, no atrophy No nuchal rigidity, no Babinski, no Kernig’s, no Brudzinski
Salient Features 4 year old female Chief complaint of facial edema Abdominal enlargement Tea-colored urine ↓ urine output Fluid wave Shifting dullness 2 ½ week history of tonsillopharyngitis