RTRMF College of Medicine, S.Y.

2018-19
Department of Pediatrics
Student: Almo, Alyssa Claire A.
Preceptor: Dr. Nicolasora
Date: November 29,2018 Date and Time of Interview:
November 22, 2018 ; 9:00 am
Source of Information: Patient’s
Mother
Reliability: 90%
Referral: None

I. IDENTIFYING DATA:
P.R.A., a 2-year old female born on November 27, 2015 at Marabut, Samar, Roman
Catholic, Filipino residing at Barangay Binkuyahan, Marabut, Samar and admitted for
the first time at EVRMC on November 17, 2018 at around 4:00 AM.

II. CHIEF COMPLAINT: Fever and Seizure

III. HISTORY OF PRESENT ILLNESS:

1 week prior to admission, the patient presented with productive cough but the
patient’s mother stated the patient could not expectorate the phlegm. No
other associated symptoms developed such as colds, fever, malaise or
anorexia. The patient was given oregano extract 1 tablespoon depending
on its availability. Her fluid intake was also increased. This offered slight
relief but did not totally alleviate the cough. No other interventions were
done.
12 hours prior to admission, around 4 pm on November 16, there was still persistence
of the cough. The patient’s mother then noticed that the patient was
feverish (temperature determined by touch) and was manifesting runny
nose after she was exposed to dew when they travelled from Tacloban.
The discharge from the patient’s nose was characterized as clear and
watery, and was accompanied by occasional sneezing. She also noted that
the patient has a palpable mass behind her ears, which was described as
circular and smooth. The mother gave her paracetamol (Calpol)
120mg/ml suspension 1 tablespoon twice with a four hour interval. She
stated that the patient would cool down 30 minutes after the
administration of the medication, which lasted for an hour and then the
patient would be feverish again. She also did tepid sponge bath thrice
during the night and noted that the patient would sweat afterwards. The
mother gave the patient more water to drink. The patient did not complain
of any pain or fatigue. The patient did not manifest other symptoms such
as pallor, rashes, vomiting, lethargy, oliguria nor decreased appetite. The
mother stated that their place of residence has new cases of dengue, but
none within their household has developed the disease. No other
intervention was done.
30 minutes prior to admission, the mother noted that the patient’s temperature was
higher than it was earlier in the night (temperature unascertained). She
was about to give the third dose of paracetamol (Calpol) to alleviate the
patient’s fever when the patient’s hands and feet were noted to be very
cold (determined by touch), especially in comparison with her body
despite being wrapped in a blanket. This was followed by an abrupt onset
 of jerky movements of her extremities and clenching of the teeth. Her
eyes rolled backwards and the mother could only see the “white” part.
The patient did not manifest drooling or neck twisting. This episode
lasted for a few seconds and the patient regained consciousness. The
mother stated that the patient was responding appropriately to her
questions after that occurrence. The significant other opted not to give
the medication (Calpol), but seek immediate management in a medical
facility, hence admission.

IV. PERSONAL HISTORY:

A. Prenatal and Birth History
The patient was born to a 25 year-old G4P3 (3013) mother who did not smoke during the
course of her pregnancy. She did, however, drink coconut wine on occasion during her
pregnancy, about 10 shot glasses per occasion or approximately 400 ml. The mother was not
exposed to any infectious diseases or radiation, or to people who were ill at the time. Her
mother had a total of 5 prenatal visits since discovering that she was pregnant at around 4
months AOG. She was given iron supplementation and did not take any other medication. She
was able to complete 5 doses of tetanus toxoid since her first pregnancy.

B. Birth History
The patient was born full term via NSVD in cephalic presentation at their home in
Marabut, Samar attended by a midwife. Her mother could not recall her birth weight but stated
that the patient had loud cry. The patient was born without any apparent complications.

C. Neonatal History
The patient was able to breastfed within an hour after birth. They went to their rural health
unit a few hours after delivery for the routine maternal and newborn care. The patient’s mother
stated that the patient was given 3 injections and an ointment over her eyes while at the RHU.
She was also able to pass meconium during the first 24 hours of life, which was black in color
with soft consistency. Patient’s mother stated that there was no yellowish hue of the patient’s
skin during the first day but also stated that she could not recall if there was any discoloration
in the succeeding days. The umbilical stump was cleaned with lukewarm water and sloughed
off a week after birth. The patient did not develop any infections or diseases during the first
month of life.

D. Feeding Pattern:
The patient was exclusively breastfed per demand for 6 months after birth. She was not
given any vitamins or water during this time. She fed per demand and the volume of milk intake
increased as he grows, however the mother could not recall the specific details such as the
interval and duration of the feeding. Complementary feeding was introduced at 7 months in
the form of infant cereal, given during breakfast and dinner with breastmilk given per demand.
Rice, egg, fruits and other food were introduced during the first teething of the patient, at 8
months. The patient did not develop any adverse reactions to the introduced food. At 12
months, the patient was started on formula milk in addition to the food and breastmilk.
Her mother stated that the patient has voracious appetite and is not a picky eater, eating
whatever is served. At present, the patient eats full meals consisting of rice, viand and
vegetables for breakfast, lunch and dinner. She also drinks a glass of formula milk during
breakfast and bedtime. The mother stated that the patient is still breastfed at times, usually
when upset or sick. Breastfeeding is usually once to 4 times per day. The patient also takes
snacks between her meals. Patient drinks around 6 glasses (approximately 1500 ml) of fluids a
day, including water and milk.
 24 HOUR DIET RECALL: on a usual day the patient eats,
Meal Food Amount
Breakfast Rice 1 serving 100 kcal
Chicken 1 serving 165 kcal
Milk 1 glass 170 kcal
Water 1 glass
AM Snack Biscuit 1 pack 120 kcal
Juice 1 pack 120 kcal
Lunch Rice 1 serving 100 kcal
Water 1 glass
pork 1 serving 250 kcal
PM Snack Bread 1 slice 80 kcal
Breastmilk 1 glass 140 kcal
Dinner Rice 1 serving 100 kcal
Water 2 glasses
Milk 1 glass 170 kcal
Chicken 1 serving 163 kcal
Total calories (from 24 hour diet recall)= 1678 kcal
RENI =1,074 kcal
Calorie excess of 604 kcal

V. GROWTH & DEVELOPMENT

The patient’s significant other stated that she did not notice any developmental
delays in her child. She was already able to smile and coo when talked to at around a month
after birth. At 4 months, the patient was able to roll over and play with rattle. Patient was able
to control head at around 5 months. She can be pulled to a sitting position at 7 months and was
able to sit on her own a month after. It was also around this time that the patient can call
significant others with mama or dada. She started creeping at 9 months and was walking with
assistance at 1 year old. She was able to walk well unsupported at 14 months.
At present, the significant other stated that the patient can converse well and already
uses full sentences that are coherent. Her mother stated that the patient does not baby talk. She
is toilet trained by day and can already urinate by herself at the comfort room. She still wears
a diaper during the night but is already able to wake up when the urge to urinate is felt. She can
also use spoon in eating, and is able to follow simple commands.

VI. BEHAVIOR
According to her mother, the patient is active and playful. She would loiter around their
house and play with her siblings which would almost always result in a fight. She sleeps from
8 pm to 7 am and takes naps from 1 pm to 4 pm. She does not suck her thumbs or bite her
nails. No complaints of pica or head banging behavior. She is enrolled in day care classes
within their neighborhood during the mornings, between 9-10 am, and participates with
activities. Her mother stated that the patient seems to be enjoying day care, as she is excited
to go there daily. She also made friends with her classmates. The mother stated that the patient
was friendly with the healthcare providers during the first few days of hospitalization,
however the patient now becomes irritable at the sight of white uniforms.
The patient urinates pale yellow to yellow urine of 100 ml 10-12 times a day depending
on her fluid intake. Bowel movement is regular at once or twice per day with soft, brown
stool.
VII. IMMUNIZATIONS
The patient is a fully immunized child under the EPI schedule with the following
immunizations:
 BCG given a few hours after birth, without adverse reactions. No scar developed.
 HepB 1st dose was given at birth, 2nd dose at 6 weeks old, 3rd dose at 14 weeks old,
without developing any adverse reactions.
 DPT 1st dose was given at 6 weeks, 2nd dose at 10 weeks old, 3rd dose at 14 weeks old;
she did not develop any untoward reaction.
 OPV 1st dose was given at 6 weeks, 2nd dose at 10 weeks old, 3rd dose at 14 weeks old,
without adverse reactions.
 Measles Vaccine was given when the patient was 9 months old and she developed low
grade fever after the vaccination. Paracetamol was given, the mother could not specify
the dosage but stated that she used a dropper and followed what was written on the
packaging.
 MMR Vaccine given when the patient was 12 months old without any adverse
reactions.

VIII. PAST MEDICAL HISTORY

The patient has no history of childhood diseases such as chickenpox, measles, rubella
or mumps. She was admitted twice before at a private medical center, both with a chief
complaint of difficulty breathing. Her first admission was on 2017 (unrecalled month), was
diagnosed with asthma, admitted for 8 days, discharged improved and\ was not prescribed with
any medications. The patient was advised to avoid dust as it is one of her triggers. .Her 2nd
admission was last June 2018 with a diagnosis of pneumonia, admitted for 7 days, discharged
improved and was prescribed with an inhaler puff (mother could not specify the medication) 2
puffs a day, one in the morning and another puff in the evening for 2 months and then advised
for follow-up, but they only complied for a month (due to financial restrictions).
She had presented with common cough and colds, as well as fever, occasionally, and
was managed supportively at their home. She would sometimes be given over-the-counter
medications such as carbocysteine or lagundi for cough, chlorphenamine maleate for colds and
paracetamol for fever. Her mother stated that she could not recall the doses but that she just
follows the instructions on the packaging, which differ depending on the age of the patient.
The patient has no history of injuries, surgeries and blood transfusions. She does not
have any allergies to food or drugs. The patient takes multivitamins (Celine) ½ teaspoon syrup
daily. No other medications were taken.

IX. FAMILY HISTORY:

The patient’s father is a 38-year old military man and is apparently well. Her mother is
a 28- year old housewife without any diagnosed health conditions and is apparently well. She
is the youngest among three children, and both her brothers are apparently healthy. The
patient’s maternal grandmother is 63 years old, alive, has hypertension and had a
cerebrovascular accident during 2016, while her maternal grandfather is 65 years old and
apparently well. The paternal grandparents are both alive and diagnosed with hypertension,
their ages were unknown to the significant other.
There is no family history of bronchial asthma, cardiovascular disease, renal or liver
diseases, thyroid disease, diabetes mellitus or cancer.
No one from the patient’s maternal family was diagnosed with asthma, but status on
the paternal side is unknown. Her housemates also did not develop the manifestations that she
presented.
X. PSYCHOSOCIAL HISTORY
The patient lives in a concrete, 1- bedroom house situated near a road. They live in a
barrio which is a few minutes away from the town center and health unit, accessible by motor
vehicles. She lives there with her parents and two older brothers. The family sleeps in their
living area and uses mosquito nets. A water-sealed toilet is located inside the house. The
household has electricity. Charcoal and gas stove are used for cooking, depending on
availability. Water for drinking is collected from a faucet and water source is from a spring
near their vicinity. They use the same water for cooking, laundry and doing the dishes. Garbage
is disposed through community collection. They have a dog in their household but this does
not sleep with the child, and is usually at their rooftop.
Both of his parents are occasional drinkers of alcoholic beverage. Her mother is a
nonsmoker, her father smokes but not within their home. Her father is often not at home due to
his career as part of the military, and the primary care provider is the mother. Patient interacts
well with other family members and is playful.

XI. REVIEW OF SYSTEMS

General: The patient did not have weight loss, no weakness, no fatigue.
Skin: Nonpruritic, flat erythematous rashes developed a day after the fever subsided. No
lumps or change in moles were noticed by the mother.
Head: No complaints of headaches, dizziness or a previous head injury.
Eyes: There were no redness, excessive tearing, itchiness, diplopia or blurring of vision.
Ears: No complaints of earache, discharges or tinnitus.
Nose and Sinuses: No epistaxis.
Mouth and Throat: No hoarseness, no sore throat, no bleeding gums.
Neck: No stiffness or any lumps.
Breast: No lumps or discharges.
Respiratory: The patient has no dyspnea, noisy breathing or colds. She did not have
hemoptysis. Productive cough noted.
Cardiovascular: No edema or jugular vein distention stated. No chest pain or palpitations.
Gastrointestinal: The patient can tolerate solid food. No melena or hematochezia. The
patient defecated once with semi formed brown stool without straining.
Urinary: No reports of dysuria. No hematuria or polyuria. She urinated thrice during the
day of the interview, significant other could not estimate the amount but stated that
it was yellow in color.
Genital: The patient has no lumps, sores or discharges.
Peripheral Vascular: No edema.
Musculoskeletal: no joint pains
Neurologic: There was no tremors, no paralysis, and no tics.
Hematologic: The patient’s mother stated that she does not easily bruise or bleed.
Endocrine: No heat and cold intolerance; and does not experience polyuria, polydipsia nor
polyphagia.

XII. PHYSICAL EXAMINATION (done on the 4th day of hospitalization)

GENERAL SURVEY
The patient was examined awake and easily irritable. She was well groomed and dressed
appropriately. She was mesomorphic in configuration, without any obvious deformities or
emaciation. No signs of dehydration noted. She does not appear to be in cardiorespiratory
distress. She presented the following vital signs and anthropometric data:
 Vital signs Actual Normal Value
Temperature 36.3 ⁰C 36.5 - 37.5 ⁰C
Heart Rate 108 bpm 65-110 bpm
Respiratory Rate 23 cpm 20-25 cpm
Blood Pressure Not taken 95-110/ 60-75 mm Hg

Anthropometric Actual Z-Score Interpretation

Data
Weight 14 kilograms 0 Normal
Height 89 cms Below 0 Normal
BMI 17.67 kg/m2 Above 0 Normal
MUAC 19 cm
HC 55 cm Above 97th
CC 47 cm
AC 65 cm

INTEGUMENT
Skin was moist with good skin turgor, with fair complexion. Patient has erythematous
macular rashes that are blanchable with pressure on both her upper and lower extremities, as
well as on her cheeks along her jaw. No rashes were noted on her neck, trunk, abdomen and
back. 2 circular bruises around 1 cm in diameter noted on the radial side of the wrist with a
needle point lesion at the centers. No edema nor active lesions noted. She also did not manifest
pallor, cyanosis or jaundice.
Nails were pink, short and with smooth edges. No clubbing evident with good capillary
refill of less than 3 seconds.
Hair was long and curly, black in color and smooth. No nits or lice infestation noted.

HEAD
The skull was normocephalic, atraumatic. There was no lumps, tenderness, engorged
veins, active lesions nor scaling noted upon examination of the scalp.

EYES:
The eyebrows were symmetrical and full with fine, black hair; no scars or active lesions
noted. The lids and globes were symmetric, without ptosis, lidlag or edema. No discharge
evident. The eyelashes were fine, black and oriented outwards. Pink, non-hemorrhagic
palpebral conjunctiva noted. The sclera was anicteric. Cornea were clear and without
ulceration. The pupils were symmetrically round, 3mm in diameter, and with brisk
reaction to direct & consensual light stimulation. Patient presented with full and intact
extraocular muscle movement by following the movement of her significant other, and
with good convergence. Unable to confirm peripheral visual fields.

EARS:
Ears were symmetrical in alignment and shape, pinna were firm. No discharges, no active
lesions, and no impacted cerumen were evident. Tenderness not elicited. Hearing acuity
good on both ears, confirmed through ability to follow mother’s voice.

NOSE & SINUSES:

Patient had pinkish nasal mucosa, with both nares patent. No nasal flaring, no discharge
nor stuffiness, no septal deviation nor nasal polyps, no epistaxis were noted. No grimace
was noted upon palpation of frontal and maxillary sinuses.
MOUTH & THROAT:
The lips were moist and pale, without angular deviations or cheilosis. The mucous
membrane was moist and pinkish, devoid of bleeding, sores and ulceration. The gums
were pale and without bleeding. The patient has 22 milk teeth of different levels of growth.
No dental carries noted. The tongue was at midline upon protrusion, pinkish and without
ulceration, papillary atrophy, fissures or tremors. The uvula was at the midline, the tonsils
were not enlarged and no exudates were noted.

NECK:
The neck was supple, with no limitation in movement. The trachea was at midline and the
thyroid gland was not palpable. There were no engorged veins and visible pulsations.
Lymph nodes were non-palpable.

BREASTS:
Nipples not inverted. No discharges noted.

CHEST AND LUNGS:

Inspection: Chest was truncal in shape with symmetrical lung expansion. No lagging, no
bulging, no supraclavicular, suprasternal, subcostal and intercostal retractions noted.
Breathing was of regular depth and rhythm. However, occasional changes in respiratory
rate was observed with a change to a more shallow breathing when patient cries then goes
back to normal.
Palpation: Symmetrical lung expansion was confirmed, with unimpaired tactile fremitus.
No tenderness over the ribs and bony prominences was elicited.
Percussion: Bibasal dullness elicited; resonance heard over other lung fields.
Auscultation: Bibasal crackles noted. Bronchovesicular breath sounds heard over the other
lung fields; no rales, no wheezing and no pleural friction rub were noted.

HEART:
Inspection: There were no visible pulsations over the precordium.
Palpation: Point of maximal impulse was palpable at the 4th ICS (L) MCL. No thrills and
heaves felt.
Auscultation: Heartbeat was regular in rhythm, synchronous with pulse at 108 per minute.
S1 is crisp, heard better at the apex, while S2 was heard louder at the base. There were no
audible murmurs, click, pericardial friction rub and extraneous heart sounds.

ABDOMEN:
Inspection: The abdomen was globular without visible peristalsis, engorged veins, or
bulging flanks. The umbilicus was inverted.
Palpation: Patient became irritable as her abdomen was touched. The liver, spleen and
kidney were not palpable upon light palpation, deep palpation not performed. The
abdomen was soft in consistency. No nodularities noted.
Percussion: Tympany note on all regions. Unable to confirm liver and splenic span.
Auscultation: Normoactive bowel sounds noted. No arterial bruit, venous hum, and
peritoneal friction rub noted.

GENITALIA AND INGUINAL REGION:

Genitalia grossly female, no discharges. Inguinal lymph nodes nonpalpable.

BACK AND SPINE:

Spine straight with no obvious deformities when erect. No deviation, no retractions, no
bulging and no muscle wasting noted. No paravertebral tenderness or mass noted.
EXTREMITIES:
Extremities were symmetrical in length, without deformities, lesions, edema and atrophy.
Muscle strength grade 5 on all extremities except right upper extremities with grade 3. No
muscular tenderness elicited. Active range of motion without pain, locking, clicking or
limitation on all joints. Peripheral pulses were graded as follows:
Pulses Brachial Radial Femoral Popliteal Posterior Tibial Dorsalis Pedis

Right 2+ Not taken 2+ 2+ 2+ 1+

Left 2+ Not taken 2+ 2+ 2+ 1+

XIII. NEUROLOGIC EXAM

I. MENTAL STATUS EXAM: The patient was examined awake but irritable. She
was able to follow simple instructions but sometimes refused to respond. Mostly
responded with mumbling and gestures.

II. CRANIAL NERVES:

 CN I: was tested but did not respond.
 CN II & III: pupils were 3mm in diameter, equally round with brisk reaction
to direct and consensual light stimulation. Corneal reflex intact.
 CN III, IV, VI: Patient was able to follow movement of her significant other
by gaze and with good convergence. Unable to confirm peripheral visual
fields.
 CN V: present symmetrical facial muscle tone without deviations upon
clenching teeth, and positive corneal reflex was elicited. Grimace noted
upon introduction of pressure stimuli.
 CN VII: symmetrical facial movements were noted. Able to raise eyebrows
and puff out cheeks. Taste not tested as patient refused.
 CN VIII: Patient was able to follow simple verbal instructions.
 CN IX and X: gag reflex elicited. Patient was able to swallow water easily.
Taste not tested.
 CN XI: was able to shrug shoulders and turn head against resistance but
weakly.
 CN XII: tongue was midline and symmetrical, no fasciculation or tremors
noted upon protrusion. The patient was able to move tongue to sides, up and
down.

III. SENSORY: grimaces when painful stimulus or pressure was applied.

IV. REFLEXES:
a. Deep tendon reflexes:

b. Pathologic reflexes: (-) babinzki (-) ankle clonus

c. Superficial reflex : (+) corneal reflex, (+) abdominal reflex
 d. Primitive reflexes: none elicited; (-) plantar, palmar, moro, tonic neck
reflexes

V. CEREBELLUM: Unable to assess gait. Rapid alternating movement, finger to nose

test, and heel shin test not performed.

VI. MENINGES:
(-) Kernig’s, (-) Brudzinski

VII. AUTONOMIC NERVOUS SYSTEM

(-) excessive sweating, (-) excessive lacrimation, (-) excessive salivation

IX. SALIENT FEATURES

 Toddler
 Previous infection: manifested by cough and cold
 Febrile seizure
 Dengue cases in their community
 Rashes manifested a day after fever resolved; characterized as erythematous macular,
non-pruritic.

X. IMPRESSION
Febrile Seizure; Dengue vs. Roseola