UPH-DR. JOSE G.

TAMAYO MEDICAL UNIVERSITY

DEPARTMENT OF PEDIATRICS

YEAR III SGD CASE 03-2022

GENERAL DATA:
WGA, 1 year old, male, Roman Catholic, from Sta. Rosa, Laguna was admitted for the
first time on April 5, 2020 at Perpetual Medical Center at 5:00PM.

CHIEF COMPLAINT: difficulty of breathing % RELIABILITY: 85%

INFORMANT: Mother

HISTORY OF PRESENT ILLNESS:

The present condition started 5 days prior to admission when the patient was noted to
have intermittent fever, moderate to high grade. He given was Paracetamol at 10mg/kg/dose
which afforded temporary relief. No consult was done.
4 days prior to admission he was noted to have non-productive cough and watery nasal
discharge. Paracetamol was continued, still no consult done.
3 days prior to admission, rashes were noted over the hairline and the cough becomes
productive.
The condition persisted until 1 day prior to consult when the patient was noted to have
generalized seizure with high grade fever. Sponge bath was done and paracetamol was given
which afforded relief.
Several hours prior to consult, he was noted to have difficulty of breathing. The patient is
still highly febrile. This prompted consult at the ER and was subsequently admitted.

REVIEW OF SYSTEM:
CNS: (-) loss of consciousness
CVS: (-) pertinent findings
GIT: (+) diarrhea
HEMA: (-) bleeding

PAST MEDICAL HISTORY:

(-) previous hospitalization
(-) childhood illness

FAMILY HISTORY:
The father is a market vendor in good health and the mother is a housewife also in good
health. She has 2 other siblings also in good health.
(+) febrile seizure – maternal side
IMMUNIZATION: Given at the Rural Health Unit
(+) BCG - (+) scar Right deltoid (-) Measles
(+) DPT/OPV – 3 doses (-) MMR
(+) Hib – 3 doses (+) Hepatis B – 3 doses

NUTRITIONAL HISTORY:
He still breastfed with complimentary feeding starting at 6 months. At present he is fond
of eating fish and vegetables.

SOCIOENVIRONMENTAL HISTORY:
The patient lives in a congested neighborhood with her grandparents on the paternal side.
Water comes from deep well and not boiled before drinking.

DEVELOPMENTAL HISTORY:
At present he can walk alone, can follow simple command and can play with other
children.

PHYSICAL EXAMINATIONS:

GENERAL SURVEY: weak-looking, in respiratory distress

Vital signs: BP: 80/50 CR: 120 RR: 60

SKIN: (+) maculopapular rashes up to chest

HEENT: dry lips

(+) hyperemic TP wall
(+) cervical lymphadenopathy

CHEST/LUNGS: with subcostal retractions, (+) crackles both lung fields

HEART: tachycardic, regular rhythm, no murmur

ABDOMEN: globular, non-tender

EXTREMITIES: no edema

NEUROLOGIC EXAM: normal

GUIDE QUESTIONS:
1. Give possible questions you want to ask the informant and other physical examinations
findings that will help you in diagnosing the case.
2. Give the salient features.
3. What is the possible diagnosis?
4. Give at least 3 differential diagnosis and the basis
5. Give the laboratory test that can be requested and the expected results
6. Explain the pathophysiology
7. What will be your plan of management?