Joanna Marie S.

Misterio
Medicine 3

December 14, 2016

Pediatrics Rotation

GENERAL DATA
Patient Name:
J.K.U.
Sex:
Male
Age:
4 months old
Date of Birth:
July 21, 2016
Address:
Mandug, Davao City

Date and Time of Admission:

December 5, 2016, 9:30 PM

Date and Time of Interview:

December 7, 2016, 4:00 PM

Informant : Mother
Reliability:

95%

CHIEF COMPLAINT: Cough and Fever

HISTORY OF PRESENT ILLNESS

Five days prior to admission, patient had an onset of a barky/hacky cough and fever
associated with runny nose. Mother self-medicated the patient with paracetamol
(Calpol) Suspension Infant Drops with unrecalled dose every four hours which
provided temporary relief of fever.
His stool was yellowish and mucoid in consistency. Few rashes were said to be
present at the anterior and posterior trunk, however, disappeared the next day.

Four days prior to admission, patient was brought to a clinic for a medical check-up.
Fever was noted to be at 38.5C and was prescribed with albuterol (Salbutamol)
three times a day, Cetirizine once a day and Zinc, all with unrecalled doses.
The following days, the patients cough was persistent and worsening, and patient
had difficulty of sleeping at night with his relentless crying.
One day prior to admission, fever recurred and cough was still progressive.
Few hours prior to admission, along with the cough and fever, patient had difficulty
of breathing and nasal flaring accompanied by incessant crying, hence, the
admission.

PAST MEDICAL HISTORY

At two days old, patient was diagnosed with urinary tract infection (UTI), manifested
with fever and hematuria. Patient was said to be injected with an unrecalled
antibiotic and was sent home after stabilization.
No previous hospital admissions and surgical procedures done.
BIRTH/PREGNANCY HISTORY
Prenatal History
The mother was primigravid when she was pregnant with the patient at 28 years
old. She had regular prenatal checkups at the local health center with an
obstetrician. Folic Acid 400mg, 1 tab, once a day was prescribed with good
compliance. She also had Calcium and ferrous sulphate, 1 tab each a day. 2 doses of
Tetanus toxoid were also given. At 5th month age of gestation, mother was admitted
due to tonsillitis and cough. She injected with an unrecalled antibiotic suppository.
No increase in blood pressure, blood sugar or any other illnesses noted during
pregnancy.
Perinatal History
On the day of delivery, the patients mother had labor lasting for approximately 8
hours. She delivered the patient full term via normal spontaneous vaginal delivery
at home assisted by her mothers aunt, a midwife. No excessive bleeding or other
complications during delivery.
Neonatal History
The mother recalled that the patient had a weak cry. There was no cyanosis or
jaundice. The birth weight was 3.2 kg; birth length and head circumference were
unrecalled.

Diet/Nutritional History
The patient was exclusively breastfed. Patient takes Tiki-tiki.
Growth and Development
At 2 months, the patient was noted to have social smile. Currently (4 months), he
was able to assume prone position with good head control.
Immunizations
He was given 1 dose of BCG and 2 doses of Pentavalent (DPT-HepB-Hib), OPV, and
PCV vaccine. Vitamin K was given IM at left thigh on July 26, 2016.

FAMILY HISTORY
Father and grandfather on paternal side have hypertension. No family history of
diabetes, cancer, tuberculosis, obesity, asthma, arthritis, metabolic syndrome,
thyroid diseases, heredofamilial diseases and mental illnesses.
SOCIAL HISTORY
Socioeconomic:
Patient was the first born. His father is 28 years old and currently working at Water
District (Disconnection Department). His mother, 28 years old, is a college graduate
and currently unemployed. The father provides the main financial support. His
biological parents are married.
Environmental:
The neighboring houses in their area are far from each other. Their house is wellventilated and with good supply of water and electricity. The patient lives with his
mother, father and uncle. His uncle is a smoker. Patient travels long distances
monthly via public transport (jeepney), exposed to dust and open air.

REVIEW OF SYSTEM
General: The patient had a fever. No significant weight changes and weakness.
Skin: Had a transient rash. No eczema, petechiae , itching or other skin lesions.
HEENT: Head. No head injuries, or trauma. Eyes. No discharge, itchiness, or
redness. Ears. No ear discharge. Nose. Occasional colds. No epistaxis, or sinusitis.
Throat. No oral mucosa lesions or inflammation, tonsilitis.
Neck: No lesions, or lumps.
Respiratory: No asthma or wheezing. See HPI.
Cardiovascular: No history of palpitations or murmurs. No known heart disease
and cyanosis.
Gastrointestinal: No change in appetite, hematochezia, constipation, diarrhea, or
melena. No rectal bleeding or black or tarry stools.
Urinary: Had a urinary tract infection and hematuria. No known problems with
urination.

Musculoskeletal: No history of fracture. No myalgia, arthralgia, swelling,

weakness or paralysis of arms and legs.
Neurologic: No changes in balance. No stiffness, seizures, dizziness or fainting.
Psychologic/ behavior: Generally seems happy and playful.
Hematologic: No anemia, bleeding, easy bruising.
Endocrine: No polyuria, polydipsia, or heat and cold intolerance.

Physical Examination
General:
Patient was examined sleeping on mothers arms. She has a weight of 2.7 kg and a
length of 93cm.
Vital Signs
Temperature: 36.2 C (left axillary, afebrile)
Respiratory rate: 68 cpm (tachypneic)
Heart rate: 121 bpm (slightly tachycardic) (normal 3-6 months: 90-120bpm)
Blood pressure: not measured
Skin, Hair and Nails
Inspection: Skin is fair in complexion and uniform in color throughout the body noted.
(-) Pallor, (-)ecchymosis and (-) hematoma. Hair is black; no infestations noted. Nails are
clean and well-trimmed, with a CRT of <2 sec.
Palpation: Skin is smooth, moist and warm to the touch.
Head and Neck
Inspection: Head is round, normocephalic and symmetrical. Neck is in the midline.
Head and neck are proportional to the body.
Palpation: No masses or lumps noted. No palpable lymph nodes and no dilated veins
palpated in the neck. Both anterior and posterior fontanelle are close.
Eyes

Inspection: Eyes are symmetrical on both sides. Eyelashes are equally distributed. No
ptosis, hordeolum or chalazion noted. Pinkish palpebral conjunctiva with non-icteric sclera
noted. Pupils equally round and reactive to light accommodation upon inspection.
Palpation: No masses, lumps or tenderness
Ears
Inspection: Ears are uniform in color, symmetrical and aligned with the outer canthus of
the eyes on both sides. External ear canal has some cerumen. No lesions, discharges and
redness noted.
Palpation: No masses, lumps or tenderness.
Nose, Throat, Mouth and Sinus
Inspection: Nose is in the midline and uniform in color with the face. Discharges noted.
Lips are pinkish but are noticeably dry. Buccal Mucosa wasn't examine because patient
refused to open mouth and lead to tantrums
Palpation: No masses, lumps or tenderness
Thorax and Lungs
Inspection: Mild substernal retractions noted. Symmetrical chest expansion. No
deformities, injuries or lesions noted.
Palpation: No masses or lumps. No tenderness noted. Tactile fremitus noted on both lung
fields.
Percussion: All lung fields resonant.
Auscultation: Mild crackles noted on both lower lung fields, more prominent on the right.
Cardiovascular
Inspection: No palpitations noted
Palpation: No heaves, thrills or lifts
Auscultation: No murmurs

Breast and Axillae

Inspection: Prepubertal breast noted
Palpation: No lumps, masses or tenderness noted.

Abdomen
Inspection: Pot belly noted, no redness, hematoma observed
Auscultation: Normoactive bowel sounds throughout the abdomen at 18 clicks/min
Palpation: Abdomen is smooth on palpation, (-) muscle guarding. No masses and lumps.
No direct and indirect tenderness noted.
Genitourinary
Inspection: Skin is unblemished and uniform in color; pubic hair is absent. (-) Labial
varicosities and tenderness, (-) inflammation and foul odor.
Musculoskeletal
Inspection: Muscle size and shape in proportion.
Palpation: Smooth and firm. Muscle tone and strength normal on both sides. No
tenderness noted.
Neurologic
The patient is awake, alert and responsive, as well as oriented to time, people and place.
He has a Glasgow Coma Scale of 15.
CN I: Sense of smell is intact, able to smell well
CN II: Sense of sight is intact able to read word
CN III, IV and VI: Extraocular muscle movements are intact
CN V: Masseter and temporalis strength intact
CN VII: Facial movements intact
CN VIII: Hearing is intact on both ears
CN IX, X: No hoarseness of voice

CN XI: Able to shrug shoulders, able to move against resistance noted

CN XII: wasn't able to assess patient express tantrums
Salient features:

3 years old
Fever
Productive cough with whitish phlegm
Mild crackles on both lower lung

fields
Vomiting
Abdominal pain

Colds

Difficulty with appetite

Passed watery stool
No chest pain
Not in respiratory distress
No weight loss
No muscle pain
No rashes

Impression: Pneumonia

Differential diagnosis:

1. Bacterial Pneumonia
2. Viral Pneumonia
3. Tuberculosis

The usual symptoms of TB include fever, fatigue, irritability, a persistent

cough, weakness, night sweats, swollen glands, poor appetite, weight loss and poor
growth. Among these symptoms, fever, loss of appetite and cough were experienced by
the patient. There were no palpable swollen glands and significant weight loss was not
observed. Apart from the clinical signs and symptoms, other factors that are combined in
order to arrive at a definite diagnosis include positive tuberculin skin test or positive TB
blood test, chest x-ray with patterns associated with TB and a history of contact with a
person with TB.

4. Upper respiratory tract infection

Infection of the upper airways cause symptoms such as cough, fever,

irritability, and colds which are all present in our patient which may lead to a possibility
that the patient has URTI. However, patients with URTI usually have nonproductive
cough, sore throat, sinusitis and clear breath sounds. These symptoms were absent upon
after examination of the patient, thus ruling this disease out.

5. Acute bronchitis

This condition often follows a viral upper respiratory infection. Cough, a

prominent feature of this disease, is present in our patient. Initially, a dry cough develops,
which after several days becomes productive with purulent sputum. Early findings include
a low- grade fever which was the initial symptom of our patient. As the disease progresses,
crackles are noted. However, upper respiratory infectious symptoms- e.g. rhinitis, which is
usually the first presentation of a patient with this disease was not manifested. Two other
common symptom of this disease which were absent in our patient are muscle pain and
sore throat.

Final diagnosis: