Case Scenario for October 19, 2022

EM, a 2-month old baby girl, was brought to OPD for check up. She was born full term to a 28-
year old G1P1 (1001) mother via spontaneous vaginal delivery in a lying-in clinic in Pasig City
last July 01, 2022. The mother claimed that her pregnancy was unremarkable. The mother and
child were sent home from the lying in clinic 24 hours after giving birth. They were advised by
the healthcare provider to bring the baby back for consult after 1 week, but was unable to
comply due to the pandemic. The mother claims that the baby was doing well.

The baby was born with a birth weight of 3.5 kg, 38 weeks AOG, AGA and APGAR score was 8
and 9. Birth length was 50 cm and head circumference was 35 cm.
At home the baby was noted to have good suck, consumed about 1-2 oz. of milk formula per
feeding. Bowel movement is 3-4 times per day. At birth, BCG, Hepatitis B and vitamin K were
given.

The present condition started when EM was brought to ARMC for consultation prior to
immunization.

The mother was 28-years old, primiparous, had her regular checkup with a midwife. Prenatal
laboratory results were within normal limits and she took her vitamins regularly. The mother
denies history of cough, colds during the first 3 months of pregnancy. She denied smoking or
intake of illegal drugs.

Upon examination of the baby, she was noted to follow moving objects and smiles. The baby
was not able to turn to her sides nor roll over.
Except for occasional spitting of milk, the other information gathered were unremarkable.
The informant denies that a family member has been treated for PTB. Maternal grandfather has
hypertension.

Both parents are working and the care of the baby is left to a caregiver. Mother and father do
not smoke nor drink alcoholic beverages. Water supply comes from maynilad and their
garbage is collected thrice a week.
The baby did not have any history of cough, colds or frequent stooling.
Currently, multivitamins drops 0.3 ml daily is being given.

At the OPD, the baby was cuddled by her mother, awake and not in respiratory distress
HR: 130/min., RR: 42/min., temp: 36.8’C, O2 sat: 97%
Weight: 4 kg., length: 52 cm., head circumference: 35 cm.
Soft skin, warm to touch, no discoloration
Open flat anterior fontanel, palpable open posterior fontanel, pink palpebral conjunctivae,
anicteric sclerae, no nasal discharge, no cleft lip/palate
Symmetrical chest expansion, no retractions, clear breath sounds

Adynamic precordium, apex beat 4th ICS, LMCL, normal S1, split S2, no murmur, good heart
tones
Slightly globular abdomen, no visible peristalsis, non palpable liver edge, bowel sounds
appreciated
No anal fissures, patent anus
Able to move upper and lower extremities, palpable pulse-inguinal areas
Normal looking female genitalia
Awake, no involuntary movements
Guide Questions:

1. Describe the different parts of pediatric history and PE.

2. Arrange the informations into their proper parts of the history and PE in chronological order.

3. Supply the information/s that are not found in the above case scenario.

4. Attempt at making a clinical impression.

5. Be ready to participate in the discussion.