Presentation on theme: "Pediatric Clinical Correlation Chronic Case Group 3 (Lim, Harold- Lipana, Kirk)"— Presentation transcript:
Pediatric Clinical Correlation Chronic Case Group 3 (Lim, Harold- Lipana, Kirk)
General Data Date of Admission: February 11, 2011 Name: Vitug, Junsen Barcas Age: 16 Sex: M Birthdate: December 24,1994 Address: Blk. 27, Lot 10, Palmera Spring II, Novaliches, Caloocan City Nationality: Filipino Religion: Roman Catholic Informant: Father and Patient Reliability: 80%
Chief Complaint “namamaga ang kanang hita” ( swelling of the right thigh )
History of Present Illness 16 yrs. PTA previously diagnosed with hemophilia A uncontrollable bleeding from a small wound admitted and transfused with unrecalled units of Factor VIII 2 yrs. PTA Patient noted swelling of the of the right thigh Spontaneous; warm; Slight limitation of movement on affected leg; (-) history of trauma Progression of swelling (whole thigh); bluish skin discoloration Patient’s mother noted a non-healing wound (lateral aspect of the right thigh) oozing with foul smelling mixture of pus and bloody discharge accompanied by a low grade fever (Paracetamol 500mg/tab)– resolved medicated wound with povidone iodine (Betadine) and dressed with sterilized gauze Admitted for debridement
2 wksPTA accidentally bumped right hip on the table pain was minimal and resolved no medications nor any consult done denied swelling or bruising immediately after the incident 1 wk PTA swelling on right hip with tenderness graded 8/10 applied cold compress given paracetamol 500mg/tab, slight relief 5 days PTA persistence of the pain and swelling stopped resolving with paracetamol Transfused with factor VIII and was advised admission; refused advised to follow up after a few days at OPD Few hrs. PTA patient followed up at the OPD Swelling not resolving hence admission
Immunization History – Completed EPI from health center until 9 months of age Past Medical History – Primary complex(treated)- 6 months of HRZE – Varicella- 9 years old – Intracerebral hemorrhage: 2008 (factor VIII infusion); resolved Family History: – Hypertension -Grandparents – Hemophilia A – Both siblings – Brain tumor- Maternal grandmother – Prostate cancer- Maternal grandfather
Developmental/ Behavioral History Home: Second of 3 siblings, lives with his parents and brothers in Caloocan Education: currently 3 rd year High School Student in Bagumbong High School in Caloocan; average academic performance Eating Behavior: good appetite, no specific food preference, five basic food groups present in daily meals Abuse: no reported sexual abuse or observed signs of physical abuse Activities: goes out with friends, stays home often Drugs: denies illicit drug use, non alcoholic beverage drinker, non smoker Sexual: denies sexual contact/activity; has not had romantic relationships Safety: wears seatbelt when riding cars; commutes often Suicidal ideations: no suicidal ideations/attempts Family: good interpersonal relationships with family members Image: good self esteem/desires opposite sex Recreation: goes to malls with family, use of internet, texts often Spiritual: regularly goes to Sunday mass Threats/Violence: no imposed harm to self or others; no reported threats
Socioeconomic/Environmental profile Patient lives in a 1-storey house with one bedroom with his immediate family. Source of drinking water from a water station and bathing water is from NAWASA. Garbage is collected once a week. The family owns a pet dog. Father is a smoker.
Physical Examination General Survey General appearance alert, coherent, cooperative, calm, not in cardiorespiratory distress, needs assistance when getting out of bed, acutely ill Body Habitus/ nutrition statusundernourished, asthenic Body SymmetrySymmetrical Personal HygieneWell groomed FaciesNo characteristic facies Mood and affectAppropriate, neutral Vital Signs Weight36kg Height5'3 ft BMI14.1 (underweight) Blood pressure110/80mmhg Pulse rate96bpm Respiratory rate20 bpm Temperature (axillary)37.1 o C
Skin Inspection Warm, no jaundice,slightly pale complexion; no skin turgor HairBlack, evenly distributed, smooth NailsNo clubbing, symmetrical, pale nail beds Mucosa Pale palpebral conjunctiva, slightly pale oral mucosa Palpation of lymph nodesLNs not enlarged
HEENT HeadSymmetrical, no active lesions, no masses, no tenderness Ears pinna well curved, symmetric, in proportion with the head, not low set, no preauricular tags, no watery, purulent, or bloody aural discharge, wet cerumen along EAC; TM: intact, pearly white, positive cone of light, no effusion or bubbles, no bulging, no peripheral erythema; mastoid: no masses, inflammation or tenderness Eyes pale palpebral conjunctiva, anicteric sclera, (-) Hirschberg, Normal pupillary reflex (direct and consensual), (+) Red orange reflex, visual acuity (20/30); cross cover test- no eye movement observed on uncovered eye (L&R) Nose both nares patent, no alar flaring, no nasal discharge, septum not deviated, no sinus tenderness, no masses within the nasal cavity, no pallor of the nasal mucosa Mouth & throat pink & dry lips, no gum bleeding or hypertrophy, no oral ulcers or vesicles tongue: moist, slightly pale; orophrayngeal mucosa: slightly pale, no thrush, no ulcers; palate& uvula: symmetrical, no bulging, no cleft, uvula midline; teeth: complete with minimal dental caries on 1 molar tooth (L) tonsils: grade +1 NeckSupple neck, trachea midline, no neck masses or nodules, no palpable lymph nodes, neck veins not distended, no thyromegaly
Pulmonary Inspection Symmetrical chest expansion, no retraction, no use of accessory muscles, no chest wall deformity, no lesions, no clubbing and cyanosis Palpation Equal vocal and tactile fremiti on both lung fields, no inflammation, no tenderness, PercussionResonant on all lung fields AuscultationClear breath sounds, no crackles, no wheezing, no egophony
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