pediatric clinical correlation chronic case

Pediatric Clinical CorrelationChronic Case

Group 3(Lim, Harold- Lipana, Kirk)

General Data• Date of Admission: February 11, 2011• Name: Vitug, Junsen Barcas• Age: 16 • Sex: M• Birthdate: December 24,1994• Address: Blk. 27, Lot 10, Palmera Spring II, Novaliches,

Caloocan City• Nationality: Filipino• Religion: Roman Catholic• Informant: Father and Patient• Reliability: 80%

Chief Complaint

“namamaga ang kanang hita” ( swelling of the right thigh )

History of Present Illness

• Immunization History– Completed EPI from health center until 9 months of

age• Past Medical History– Primary complex(treated)- 6 months of HRZE– Varicella- 9 years old– Intracerebral hemorrhage: 2008 (factor VIII infusion);

resolved• Family History:– Hypertension -Grandparents– Hemophilia A – Both siblings– Brain tumor- Maternal grandmother– Prostate cancer- Maternal grandfather

Developmental/ Behavioral History• Home: Second of 3 siblings, lives with his parents and brothers in Caloocan• Education: currently 3rd year High School Student in Bagumbong High School in

Caloocan; average academic performance• Eating Behavior: good appetite, no specific food preference, five basic food

groups present in daily meals• Abuse: no reported sexual abuse or observed signs of physical abuse• Activities: goes out with friends, stays home often• Drugs: denies illicit drug use, non alcoholic beverage drinker, non smoker• Sexual: denies sexual contact/activity; has not had romantic relationships• Safety: wears seatbelt when riding cars; commutes often• Suicidal ideations: no suicidal ideations/attempts• Family: good interpersonal relationships with family members• Image: good self esteem/desires opposite sex• Recreation: goes to malls with family, use of internet, texts often• Spiritual: regularly goes to Sunday mass • Threats/Violence: no imposed harm to self or others; no reported threats

Socioeconomic/Environmental profile

• Patient lives in a 1-storey house with one bedroom with his immediate family.

• Source of drinking water from a water station and bathing water is from NAWASA.

• Garbage is collected once a week.• The family owns a pet dog.• Father is a smoker.

Review of SystemsGeneral: (+) anorexia; (-) fever; (-) easy fatigability

Skin: see HPI

HEENT: (-) eye pain, discharge; (-) deafness, tinnitus, aural discharge occasional gum bleeding (-) neck stiffness; (-) sore throat

Cardiac: (-) palpitations (-) syncope; (-) orthopnea; (-) cyanosis

Pulmonary: (-) chest pain; (-) cough; (-) dyspnea

Gastrointestinal: (-) melena; (-) hematochezia; (-) constipation; (-) diarrhea; (-) abdominal pain

Genitourinary: (-) polyuria; (-) frequency; (-) hematuria; (-) dysuria

Musculoskeletal:

(+) limitation in body movement; (-) joint pain; (-) joint swelling; (-) bone pain

Vascular: see HPI

Endocrine: (-) polydipsia; (-) polyphagia; (-) polyuria; (-) heat/ cold intolerance

Neurologic: (-) headache; (-) seizure; (-) hallucinations; (-) memory loss

Hematopoietic (+) pallor; (+) easy bruisability

Physical ExaminationGeneral Survey

General appearance alert, coherent, cooperative, calm, not in cardiorespiratory distress, needs assistance when getting out of bed, acutely ill

Body Habitus/ nutrition status undernourished, asthenicBody Symmetry SymmetricalPersonal Hygiene Well groomedFacies No characteristic faciesMood and affect Appropriate, neutral

Vital SignsWeight 36kgHeight 5'3 ftBMI 14.1 (underweight)Blood pressure 110/80mmhgPulse rate 96bpmRespiratory rate 20 bpmTemperature (axillary) 37.1o C

Skin

Inspection Warm, no jaundice ,slightly pale complexion; no skin turgor

Hair Black, evenly distributed, smooth

Nails No clubbing, symmetrical, pale nail beds

Mucosa Pale palpebral conjunctiva, slightly pale oral mucosa

Palpation of lymph nodes LNs not enlarged

HEENTHead Symmetrical, no active lesions, no masses, no tendernessEars pinna well curved, symmetric, in proportion with the head, not low set, no

preauricular tags, no watery, purulent, or bloody aural discharge, wet cerumen along EAC; TM: intact, pearly white, positive cone of light, no effusion or bubbles, no bulging, no peripheral erythema; mastoid: no masses, inflammation or tenderness

Eyes pale palpebral conjunctiva, anicteric sclera, (-) Hirschberg, Normal pupillary reflex (direct and consensual), (+) Red orange reflex, visual acuity (20/30); cross cover test- no eye movement observed on uncovered eye (L&R)

Nose both nares patent, no alar flaring, no nasal discharge, septum not deviated, no sinus tenderness, no masses within the nasal cavity, no pallor of the nasal mucosa

Mouth & throat

pink & dry lips, no gum bleeding or hypertrophy, no oral ulcers or vesiclestongue: moist, slightly pale; orophrayngeal mucosa: slightly pale, no thrush, no ulcers; palate& uvula: symmetrical, no bulging, no cleft, uvula midline; teeth: complete with minimal dental caries on 1 molar tooth (L)tonsils: grade +1

Neck Supple neck, trachea midline, no neck masses or nodules, no palpable lymph nodes, neck veins not distended, no thyromegaly

Pulmonary

Inspection Symmetrical chest expansion, no retraction, no use of accessory muscles, no chest wall deformity, no lesions, no clubbing and cyanosis

Palpation Equal vocal and tactile fremiti on both lung fields, no inflammation, no tenderness,

Percussion Resonant on all lung fieldsAuscultation Clear breath sounds, no crackles, no wheezing, no

egophony

Lung Auscultogram

CardiovascularJVP 3cm at 30o

Carotid Pulse Rapid upstroke, gradual downstrokePeripheral pulses ++Precordium AdynamicInspection No visible pulsationPalpation 5th LICS MCL, no heaves, thrills or liftsAuscultation S1<S2 apex; S1>S2 base; no murmurs

Heart Auscultogram

Inspiration Expiration S1 S2 S1 S2

Jugular venous pulsation Carotid artery pulsation

Adynamic precordium Apex beat: 5th LICS MCL Apex: S1 is louder than S2 Base: S2 is louder than S1 No S3 or S4. No murmurs No heaves, no thrills, no lifts