PEDIATRICS WARD WORKS

VMUF COLLEGE OF MEDICINE

GENERAL DATA

• This is a case of Patient A.P, 2 months old, female, Filipino, roman catholic, and currently residing Libas san carlos city pangasinan. Admitted for the second time in PPH.

• Source of information: mother, 90% reliability

Chief complaint: • Siezure for 30 minutes

History of present illness• 2 days prior to admission, the patient experienced high grade

intermittent fever.(mother cannot recall the temperature of the patient). No associated vomiting, and rashes noted. Acetaminophen oral (tempra) was taken to relieve the symptoms. Fever was relieved.

• Few hours prior to admission, mother noticed the baby is often irritable and noticed bluish discoloration on the patients face and lips.

• 30 minutes prior to admission, the patient experienced seizure associated with fever and bluish discoloration of the face and extremeties hence rushed in PPH

• Past medical history:• Patient had his first hospitalization in PPH due to his

delivery. No birth complications and illnesses prior to hospitalization. Immunization is complete.

• Birth history:• Patient was born via NSD. Mother had regular prenatal

check up; and no birth injuries noted.• Feeding history• Breasfed from birth up to present. Patient is breasfed 4x

in a day.

Growth and development:Normal developmental milestone.

General milestone

age milestone

birth Turns head side to sideKeeps hands tightly fisted(fine motor milestone)Attunes to human voiceDevelops differential recognition of parents voice(basic language milestone)

Primitive reflexes (all normal)Primitive reflexes appears dissappears

Moro reflex, symmetrics abduction and extension of arms with trunk extension, followed by adduction of upper extremeties

birth 4 months

Hand grasps, reflex grasps of any object placed in palm

birth 1-3 months

Rooting reflex, turning of head towards same side as stimulus when corner of infant’s mouth is stimulated

birth 6 months

• Family history• Parents had no history of asthma, hypertension, kidney disease, diabetes,

cancer or any heredo familial diseases.•  • Personal and social history• The patient is the only child in the family.The patient lives in a medium

sized build house.water supply is mineral water, garbage is being collected every Tuesday of the week. No relevant travel history of the patient.

• The patient sleep 10 hours. The patient is not irritable.

REVIEW OF SYSTEMS• A. General• [+] fever [-] chills [-] malaise [-] fatigability [-] weight change • B. Integumentary• [-] pruritus [-] dark pigmentation [-] lesions/sores (-) rash (+) bluish discoloration

• C. Head and Neck• [-] headache [-] dizziness [-] head injuries [-] syncope [-] blurring of vision

• [-] diplopia [-] photophobia [-] eye pain• [-] ear pain [-] hearing loss [-] ear discharge [-] tinnitus • [-] vertigo [-] loss of sense of smell [-] nasal obstruction [-] hoarseness• [-] sore throat [-] disturbance of taste

• D. Respiratory• [-] dyspnea [-] chest pain [-]cough [-] orthopnea• [-] trepopnea [-] platypnea [-] sputum: • E. Cardiovascular• [-] easy fatigability [-] palpitation [-] dyspnea [-] orthopnea • [-] chest pain [-] shortness of breath [-] PND• F. Gastro-intestinal• [-] poor appetite [-] dysphagia [-] nausea [-] odynophagia [-] vomiting• [-] hematemesis [-] constipation [-] diarrhea [-] abdominal pain [-]

flatulence• [-] abdominal enlargement [-] steatorrhea [-] hematochezia [-] melena

• G. Genito-urinary• [-] dysuria [-] anuria [-] flank or suprapubic pain [-] polyuria• [-] oliguria [-] hematuria [-] frequency [-] incontinence [-] dribbling• [-] passage of stone [-] discharge•  • H. Musculoskeletal• [-] muscles pain [-] joint pain & stiffness[-] swelling [-] weakness• [-] bone deformity [-] restriction of motion[-] contractures [-] atrophy

• I. Neurologic• [-] syncope [-] weakness or paralysis [+] seizures [-] headache• [-] tremors [-] loss of memory [-] depression [-] dizziness• [-] delirium [-] hallucination•  • J. Endocrine• [-] weight gain [-] heat intolerance [-] goiter [-] polyuria [-] cold

intolerance [-] abnormal growth [-] polydipsia [-] polyphagia•  • K. Hematologic• [-] easy bruisability [-] easy fatigability [-] pallor

PHYSICAL EXAMINATION

• General survey• The patient is calm and cooperative.• Vital signs:• Temperature: 36.3• Heart rate: 163• Pulse rate: 25• Respiratory rate: 72• Head circumference: 38.5 cm• Weight: 5.2 kg• Length: 57 cm

• HEENT• Head: finely distributed hair, no lesions or any lump.• Eyes: symmetrical eyelids, white sclera, pink conjunctiva, no lesions any

sores• Ears: no discharge, tympanic membranes without erythema with good

cone of light bilaterally• Nose: no discharge, moist nasal mucosa• Throat: no ulcer on oral mucosa,no exudates• Skin: moist; no rash, no erythema, and no bluish discolorations.

• Neck: no lymphadenopathy, no nuchal rigidity noted• CV: no murmurs, no thrills or heaves palpated.• Resp: positive inspiratory crackles noted; no retractions• Abd:no tenderness, bruits, and any lesions or scars..• GU: normal appearing external genitalia; • Ext: warm, symmetric tone, muscle development and strength • Neuro: no atrophy; moves all extremities equally

Case discussion:

• Subjective: high grade intermittent fever and seizure for 30 minutes, associated with irritability, bluish discoloration of the face and extremities.

• Assessment: this is most likely to be the manifestation of febrile seizure.

• Treatment plan:• Give acetaminophen 250 mg q4-6 hours.• IV fluid if necessary

• Subjective: high grade intermittent fever• Objective: respiratory crackles upon examination.• Assessment: this is most likely to be the

manifestation of Pneumonia.• Treatment plan: antimicrobial therapy-

Ceftriaxone or cefotaxime can be administered as a single agent (for >28 d to 5 y). 

• Differential diagnosis• Febrile siezure• Meningitis• Pneumonia

Final diagnosis according to laboratories result:

• Bilateral subdural empyema