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General Data P.A. 4y/o, F Quezon City Roman Catholic/Filipino Date of admission: 4/29/10 Informant: mother Reliability: good.

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Presentation on theme: "General Data P.A. 4y/o, F Quezon City Roman Catholic/Filipino Date of admission: 4/29/10 Informant: mother Reliability: good."— Presentation transcript:

1 General Data P.A. 4y/o, F Quezon City Roman Catholic/Filipino Date of admission: 4/29/10 Informant: mother Reliability: good

2 Chief complaint FACIAL EDEMA

3 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

4 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

5 History of Present Illness -Consult at a local clinic -Urinalysis, BUN, Creatinine, ESR -Persistence of symptoms 2 days PTA Admission 1 day PTA

6 Review of Systems General: (-) weight loss, (-) loss of appetite Cutaneous: (-) pigmentation, (-) hair loss, (-) pruritus. HEENT: (+) headache, (-) visual difficulties, (-) lacrimation, (-) aural discharge, (-) epistaxis, (-) toothache. Gastrointestinal: (-) vomiting, (-) diarrhea, (-) constipation, (+) passage of worms, (+) abdominal pain, (-) jaundice, (-) food intolerance. Genitourinary: urine yellow in color, (-) burning sensation, (-) discharge

7 Review of Systems Endocrine: (-) palpitation, (-) cold or heat intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia. Nervous/Behavioral: (-) tremors, (-) convulsions, (-) weakness or paralysis, (-) mental deterioration, (-) mood changes, (-) hallucinations. Musculoskeletal: (-) swelling of bones/joints, (-) stiffness, (-) limping. Hematology: (-) pallor, (-) bleeding manifestations, (-) easy bruisability.

8 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

9 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

10 Past Illnesses (+) bronchopneumonia (2006) (+) mumps (unrecalled date) (-) surgeries or blood transfusions (-) known allergies (-) asthma

11 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

12 Family History (+) HPN – father (-) Renal disease (-) DM (-) PTB (-) Asthma (-) CA

13 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

14 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

15 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.

16 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.

17 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

18 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

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