6 History of Present Illness 3 weeks PTAintermittent cough, productive of whitish phlegmNo associated signs and symptomsconsult at a private clinicAmbroxol (unrecalled dosage) No reliefAmoxicillin 6.75 mg No relief
7 History of Present Illness 2 weeks PTApersistence of symptomsconsult at a private clinicCarbocisteineCo-trimoxazole (unrecalled dosage)Phenylpropanolamine (Disudrin) 0.5 ml QIDPhenylephrine HCl, chlorphenamine (Neozep) 0.5 ml QIDNo reliefCarbocisteine (50 mg/ml)Co-trimoxazole (8-10 mg/kg/day divided in 2 doses for trimethoprim; mg/kg/day in 2 divided doses of sulfamethoxazole)Phenylpropanolamine 6.25 mg/ml (Disudrin) 0.5 ml QIDPhenylephrine HCl 6.25 mg/ml, chlorphenamine maleate 0.5 mg/ml (Neozep) 0.5 ml QID
8 History of Present Illness 2 days PTApersistence of symptoms(+) undocumented fever(+) Difficulty of breathingNo consult doneParents self-medicated patient with Paracetamol drops 8.45 mg/kg/doseParacetamol drops (10 mg/kg/dose)
9 History of Present Illness Morning PTApersistence of symptoms(+) rhinorrhea, productive of yellowish-green mucous(+) vomiting milk and phlegm (about 4 oz)Consult at health centerCephalexin mg/kg/dayParacetamol 8.45 mg/kg/doseIncrease in fever(+) cyanosis of distal extremitiesCephalexin (25-50 mg/kg/day)Paracetamol (10 mg/kg/dose)PCGH ER
10 Review of Systems Constitutional: no weight loss, no weakness Integument: (+) rashes (diaper), no changes in colorRespiratory: no hemoptysisGastrointestinal: no changes in bowel movementGenitourinary: no frequency
11 Past Medical History no previous hospitalization no previous operationsno history of trauma
12 Family Medical History Liver disease, Tuberculosis - Maternal sideBreast cancer - Paternal side(-) Asthma(-) DM(-) Hypertension, cardiac disease
13 Developmental History patient is a 4 mo., male(+) grasps object placed in hand(+) moves head toward sound(+) reaches for objects(+) chews(+) roll over(-) chest up, arm support
14 Immunization HistoryBCG doseOPV doseHepa B doseNo HiB
15 Birth HistoryBorn 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
16 Nutritional HistoryBreast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day)No known food allergy
18 Personal Social history Only ChildMother y/onot employedFather y/ofactory workerParents not marriedFamilies are not on good terms
19 Environmental history Patient does not stay permanently in one household. He is shuttled from the mother’s household to the father’s household and vice versaLives in a 1 story wooden house near the streets with 2 bedrooms.The house is well ventilated and well lighted.
20 Environmental history Their water supply comes from Manila Waters.Drinking water of the patient was previously Wilkins, but now the water comes from a refill stationGarbage is collected every day.
21 Physical Examination General Survey: Vital signs: Anthropometrics: Conscious, alert, in mild respiratory distress, well-nourishedVital signs:HR 165, RR 38, Temp 40.5oCAnthropometrics:Length 59 cm (<3rd percentile)weight 7.4 kg (50-85th percentile for age, >97th percentile for length)HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm
22 Physical Examination Skin: HEENT and neck: normal skin color, good turgor (CRT<2 sec), flushed skin(+) diaper rash, inguinal area extending to buttocks, (-) lesions, flushed skinHEENT and neck:flat, open anterior fontanel; closed posterior fontanelNormal hair distribution, (-) masses/depressionsanicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm ERTL(-) ear deformities, (-) discharge, (+) intact tympanic membrane, (+) cone of light(-) nasal deformities, (+) rhinorrhea, yellow-green discharge slightly dried(-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy, supple neck, flat neck veins
23 Physical Examination Heart: Lungs: adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm(-) murmurs, good S1/S2Lungs:(-) scars or masses, (+) intercostal/subcostal retractionssymmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields
25 Physical Examination Extremities: full and equal pulses, (-) edema, (-) cyanosis
26 Neurologic Examination Cranial Nerves:CN I - not testedCN II – 3-4 mm equally reactive to lightCN III, IV, VI – intact EOMsCN V – reacts to facial sensory stimulationCN VII – no facial asymmetry, able to smile and cryCN VIII – responds to sound and verbal stimuliCN IX, X – able to feed, good suckCN XI – able to turn head from side to sideCN XII – tongue midline
27 Neurologic Examination Sensory: responds to stimuli (light touch)Motor: good muscle tone and strengthReflexes(+) Babinski(+) palmar grasp(-) rooting(-) moro(-) tonic neck
28 Salient Features4 mo./Mfever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomitingmedications given afforded no reliefon PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields
29 Admitting Diagnosis Pediatric Community Acquired Pneumonia, Category C (+) fever, difficulty of breathing, cyanosis, cough and coldsPLUS findings on PE: (+) tachycardia, (+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles
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