CASE CONFERENCE Ang, Kevin Aningalan, Arvin Antonio, Aby Aramburo, Jan Cruel, Anna

General Info J.R. 1 yr and 11 mos, Female Santa Cruz, Manila

History of Present Illness Mother palpated 1x1 movable, firm, non-tender mass over R lateral aspect of neck No other symptoms noted 6 weeks PTC

History of Present Illness Patient experienced intermittent low- grade fever (37.8°C), occurring at night time No accompanying symptoms – no anorexia – no weight loss – no cough – no colds – no medications given – no consult given 2 weeks PTC

History of Present Illness Patient experienced fever, now accompanied with colds and clear liquid discharge, (-) cough (-) anorexia (-) weight loss (-) irritable (-) difficulty of breathing 8 days PTC

History of Present Illness Patient sought consult at OPD – (+) boggy turbinates – (+) cervical lymphadenopathy, 1x1cm movable, firm, non-tender over R lateral aspect of neck Assessment: to r/o PTB Plans: PPD, CXR, to follow-up with results 5 days PTC

History of Present Illness PPD test: 10mm CXR PA and Lateral: Normal Consult

Review of Systems (-) weight loss, (-)anorexia (-) itchiness, pigmentation, rash, active dermatoses (-) blurring of vision, redness, itchiness, Iacrimation (-) deafness, tinnitus, aural discharge (-) anosmia, epistaxis, sinusitis, nasal discharge (-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion (-) chest pain, nocturnal dyspnea, palpitation, syncope, edema (-) phlebitis, varicosities, claudication (-) dysphagia, nausea, vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea, constipation (-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia (-) joint stiffness, joint pain, muscle pain, cramps (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, depression, seizures

Past Medical History No Previous Surgeries Past Medical Illnesses – Acute pyelonephritis (January 2009) – Acute rhinitis (February 2009) – Acute nasopharyngitis, probably viral (September 2009) Immunizations: complete Hepa B1,2,3 Hib 1,2,3 DPT 1,2,3 booster BCG OPV 1,2,3 booster Measles Allergies: none

Family History (+) Hypothyroidism – mother (+) Hypertension – mother (+) DM – grandfather (-) Cardiovascular diseases, stroke

Birth and Gestational History Patient born to a G2P1 unemployed 31 y/o homemaker married to a 34 y/o seaman. AOG weeks Outcome was live term singleton female delivered via NSD AS 8,9 MT wks AGA BW 3.01 BL 47 HC 33.5 CC 31.5 AC 30. On the first HOL, patient active, pink with good cry, HR at 140s, (+) S2 split on L SB, RR 45, clear BS. Breastfeeding encouraged for mins, 15 mins each breast. Advised to have TSH, T3 and T4 on the 72 nd HOL.

TSH, T3, T4 ValueInterpretationNormal Values T30.5 nM/LDecreased nM/L T4191 nM/LNormal nM/L TSH6.13 uiU/mlNormal uIU/ml

Maternal History Denied exposure to VED and radiation Denied alcohol intake nor any illicit drugs/abortifacient drugs, non-smoker. Has hypertension, hypothyroidism since 2003 maintained on levothyroxine Menarche: 14 y/o, menstrual cycle days, 1 st sexual contact: 22 y/o

Prenatal Care Prenatal care USTH, 7 weeks Antenatal UTZ, 7 mos AOG normal

Physical Examination General Survey: Conscious, awake, not in cardiorespiratory distress Vital Signs: BP 90/60mmHg HR 90bpm, regular RR 20cpm, regular T 36.7 o C Length: 82.5cm (Z score above 0) Weight: 15kg (Z score above 0) BMI: Skin: Warm moist skin, no rashes, no jaundice, no active dermatosis Head: Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, (+) nasoaural discharge, turbinates congested, no oral ulcers, moist buccal mucosa, non- hyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

Physical Examination Adynamic precordium, apex beat at 4 th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs Supple neck, prominent SCM, trachea at midline Symmetrical chest expansion, no barrel chest, no supraclavicular retractions, clear breath sounds Abdomen flabby, no scars, normoactive bowel sounds, tympanitic all over, no direct or rebound tenderness, no masses

Assessment Pulmonary tuberculosis Disease

Plans Prescribed with: – Isoniazid 200mg/5ml, 1.5 ml (5mg/kg/d) OD – Rifampicin 200mg/5ml, 3 ml (10mg/kg/d) OD – Pyrazinamide 250mg/5ml, 3.5 ml (15mg/kg/d) OD – Streptomycin 1g/2ml, 0.5 ml IM (22mg/kg/d) OD