Presentation is loading. Please wait.

Presentation is loading. Please wait.

??? Group 1: RxMen Angustia Ayes Chan Co Garcia Macapinlac Tumibay Vega.

Similar presentations

Presentation on theme: "??? Group 1: RxMen Angustia Ayes Chan Co Garcia Macapinlac Tumibay Vega."— Presentation transcript:

1 ??? Group 1: RxMen Angustia Ayes Chan Co Garcia Macapinlac Tumibay Vega


3 O Purpose of the presentation O Impact of illness to the patient and family O Coping mechanism O Family dynamics O Social resources

4 General Data O AP O 4 mos./Male O Filipino O Roman Catholic O Residing in San Miguel, Pasig City O Informant: Mother, Father, and Paternal Grandparents O Reliability: 70% O Admitted at PCGH on December 3, 2010

5 Chief Complaint O Fever (2 days)

6 History of Present Illness O 3 weeks PTA O intermittent cough, productive of whitish phlegm O No associated signs and symptoms O consult at a private clinic O Ambroxol (unrecalled dosage) No relief O Amoxicillin 6.75 mg No relief

7 History of Present Illness O 2 weeks PTA O persistence of symptoms O consult at a private clinic O Carbocisteine O Co-trimoxazole (unrecalled dosage) O Phenylpropanolamine (Disudrin) 0.5 ml QID O Phenylephrine HCl, chlorphenamine (Neozep) 0.5 ml QID O No relief

8 History of Present Illness O 2 days PTA O persistence of symptoms O (+) undocumented fever O (+) Difficulty of breathing O No consult done O Parents self-medicated patient with Paracetamol drops 8.45 mg/kg/dose

9 History of Present Illness O Morning PTA O persistence of symptoms O (+) rhinorrhea, productive of yellowish-green mucous O (+) vomiting milk and phlegm (about 4 oz) O Consult at health center O Cephalexin mg/kg/day O Paracetamol 8.45 mg/kg/dose O Increase in fever O (+) cyanosis of distal extremities PCGH ER

10 Review of Systems O Constitutional: no weight loss, no weakness O Integument: (+) rashes (diaper), no changes in color O Respiratory: no hemoptysis O Gastrointestinal: no changes in bowel movement O Genitourinary: no frequency

11 Past Medical History O no previous hospitalization O no previous operations O no history of trauma

12 Family Medical History O Liver disease, Tuberculosis - Maternal side O Breast cancer - Paternal side O (-) Asthma O (-) DM O (-) Hypertension, cardiac disease

13 Developmental History O patient is a 4 mo., male O (+) grasps object placed in hand O (+) moves head toward sound O (+) reaches for objects O (+) chews O (+) roll over O (-) chest up, arm support

14 Immunization History O BCG - 1 dose O OPV - 1 dose O Hepa B - 1 dose O No HiB

15 Birth History O Born 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 History O Breast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day) O No known food allergy

17 Genogram (12/30/10) I II III mos

18 Personal Social history O Only Child O Mother - 18 y/o not employed O Father - 20 y/o factory worker O Parents not married O Families are not on good terms

19 Environmental history O Patient does not stay permanently in one household. He is shuttled from the mothers household to the fathers household and vice versa O Lives in a 1 story wooden house near the streets with 2 bedrooms. O The house is well ventilated and well lighted.

20 Environmental history O Their water supply comes from Manila Waters. O Drinking water of the patient was previously Wilkins, but now the water comes from a refill station O Garbage is collected every day.

21 Physical Examination O General Survey: O Conscious, alert, in mild respiratory distress, well-nourished O Vital signs: O HR 165Temp 40.5 o C O HR 165, RR 38, Temp 40.5 o C O Anthropometrics: O Length 59 cm (<3rd percentile) O weight 7.4 kg (50-85th percentile for age, >97 th percentile for length) O HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm

22 Physical Examination O Skin: O normal skin color, good turgor (CRT<2 sec), flushed skin O (+) diaper rash, inguinal area extending to buttocks, (-) lesions, flushed skin O HEENT and neck: O flat, open anterior fontanel; closed posterior fontanel O Normal hair distribution, (-) masses/depressions O anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm ERTL O (-) ear deformities, (-) discharge, (+) intact tympanic membrane, (+) cone of light O (-) nasal deformities, (+) rhinorrhea, yellow-green discharge slightly dried O (-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy, supple neck, flat neck veins

23 Physical Examination O Heart: O adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm O (-) murmurs, good S1/S2 O Lungs: O (-) scars or masses, (+) intercostal/subcostal retractions O symmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields

24 Physical Examination O Abdomen: O globular abdomen, (-) masses or scars O Normoactive bowel sounds O tympanitic abdomen O (-) tenderness, (-) organomegaly O Genital exam: O grossly male, (-) deformities O Descended testes

25 Physical Examination O Extremities: O full and equal pulses, (-) edema, (-) cyanosis

26 Neurologic Examination O Cranial Nerves: O CN I - not tested O CN II – 3-4 mm equally reactive to light O CN III, IV, VI – intact EOMs O CN V – reacts to facial sensory stimulation O CN VII – no facial asymmetry, able to smile and cry O CN VIII – responds to sound and verbal stimuli O CN IX, X – able to feed, good suck O CN XI – able to turn head from side to side O CN XII – tongue midline

27 Neurologic Examination O Sensory: responds to stimuli (light touch) O Motor: good muscle tone and strength O Reflexes O (+) Babinski O (+) palmar grasp O (-) rooting O (-) moro O (-) tonic neck

28 Salient Features O 4 mo./M O fever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomiting O medications given afforded no relief O on PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields

29 Admitting Diagnosis O Pediatric Community Acquired Pneumonia, Category C O (+) fever, difficulty of breathing, cyanosis, cough and colds O PLUS findings on PE: (+) tachycardia, (+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles

Download ppt "??? Group 1: RxMen Angustia Ayes Chan Co Garcia Macapinlac Tumibay Vega."

Similar presentations

Ads by Google