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    Case of KM

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    Patty Reyes
    This document summarizes the medical history and physical examination of an 8-year-old male child named KM who presented with enlarged tonsils and a history of snoring, apneas, and restless sleep. Examination found enlarged tonsils and a neck circumference of 28cm. The patient's mother reported a history of snoring since age 3, witnessed apneas, hyperactivity, and frequent tonsillitis. A sleep study showed severe obstructive sleep apnea. The impression was chronic hypertrophic tonsils and severe pediatric obstructive sleep apnea.

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    Case of KM

    Uploaded by

    Patty Reyes
    51 views28 pages
    This document summarizes the medical history and physical examination of an 8-year-old male child named KM who presented with enlarged tonsils and a history of snoring, apneas, and restless sleep. Examination found enlarged tonsils and a neck circumference of 28cm. The patient's mother reported a history of snoring since age 3, witnessed apneas, hyperactivity, and frequent tonsillitis. A sleep study showed severe obstructive sleep apnea. The impression was chronic hypertrophic tonsils and severe pediatric obstructive sleep apnea.

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    This document summarizes the medical history and physical examination of an 8-year-old male child named KM who presented with enlarged tonsils and a history of snoring, apneas, and restless sleep. Examination found enlarged tonsils and a neck circumference of 28cm. The patient's mother reported a history of snoring since age 3, witnessed apneas, hyperactivity, and frequent tonsillitis. A sleep study showed severe obstructive sleep apnea. The impression was chronic hypertrophic tonsils and severe pediatric obstructive sleep apnea.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    51 views28 pages

    Case of KM

    Uploaded by

    Patty Reyes
    This document summarizes the medical history and physical examination of an 8-year-old male child named KM who presented with enlarged tonsils and a history of snoring, apneas, and restless sleep. Examination found enlarged tonsils and a neck circumference of 28cm. The patient's mother reported a history of snoring since age 3, witnessed apneas, hyperactivity, and frequent tonsillitis. A sleep study showed severe obstructive sleep apnea. The impression was chronic hypertrophic tonsils and severe pediatric obstructive sleep apnea.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 28

    Case of KM

    • 8 years old
    • Male
    • child
    • Quezon City

    • Informant: Patient and Mother


    Chief Complaint
    • Enlarged tonsils
    History of Present Illness
    • The mother noted snoring
    • No sudden awakening
    • No changes in sleep pattern/frequent awakening
    • No daytime somnolence
    6 years • No pauses
    • No consult was done
    PTC

    • The mother noticed that the patient’s snoring became louder, and though that it was just normal
    during that time.
    • No note of sudden awakening
    • No pauses or gasping
    • No frequent arousals
    3 years PTC • Restless sleep
    • Notice of enlarged tonsils and frequent occurrence of tonsillitis
    History of Present Illness
    •Still with snoring
    •With witnessed apneas

    7 •Restless sleep
    •snorting
    •The mother also noted that the patient was hyperactive some times

    months •The mother also verbalized that the patient would have tonsillitis more about 3 times a year since 3 years
    •No consult was done

    PTC

    •The patient had followed up in the health center after having another episode of tonsillitis
    •The patient was advised to have a sleep study done at this time

    3 month PTC

    •The patient was able have the sleep study done and it showed severe obstructive sleep apnea with desaturation
    •The patient was then advised to have surgery done hence referral to SLMC

    1 month PTC
    Past Medical History
    • No known allergies
    • No previous hospitalizations
    Maternal and Birth History
    • Born term to a then 26-year-old G1P0 mother
    via Normal Spontaneous delivery
    • No fetomaternal complications noted
    • With UTI during pregnancy (2nd term)
    Nutritional History
    • Started on formula milk after 1 week
    • Consumes 3 complete meals with snacks in between
    Developmental History
    • Able to walk, run, jump, and participate in PE
    class
    • Able to read and write
    • Participates in group play
    • At PAR with children his age
    Personal and Social History
    • Lives in Quezon City with Parents and sibling
    • Grade 3 student
    Family History
    • (+) hypertension - mother
    • (+) diabetes – father
    • (-) asthma
    • (-) Goiter
    • (-) Stroke
    • (-) Cancer
    Review of Systems
    • General: No weight loss, easy fatigability, or
    generalized weakness. No fever,
    • Skin: No active lesions or rashes.
    • Head: No headache, dizziness, or head trauma.
    • Eyes: No blurring of vision on the right eye, itchiness,
    redness, swelling, tearing or eye pain.
    • Ears: No tinnitus, loss of hearing, or abnormal ear
    discharge.
    • Nose. No colds, cough.
    • Mouth. No pain or tenderness
    Review of Systems
    • Throat: No voice changes, sore throat, dysphagia, or
    odynophagia.
    • Cardiovascular: No palpitations or chest pain.
    • Respiratory: No cough, dyspnea, or hemoptysis.
    • Gastrointestinal: No abdominal pain, diarrhea,
    constipation, hematemesis, melena, or hematochezia.
    • Genitourinary: No dysuria or hematuria.
    • Hematopoietic: No easy bruising or easy bleeding.
    • Musculoskeletal: No joint or muscle pain.
    • Neurologic: No seizures or loss of consciousness.
    PHYSICAL EXAM
    General
    –Stable vital signs
    –Awake, comfortable not in cardiorespiratory
    distress
    –Oriented to person, place and time
    –BP: 110/70, PR: 92, RR: 19, Temp: 36.8;
    –Weight: 42kg;
    –height: 111.76cm
    –BMI 35
    PHYSICAL EXAM
    EAR
    RIGHT:
    – Patent EAC
    – Intact TM
    – Cone of light present
    – No bulging or retraction
    – No discharge

    LEFT:
    – Patent EAC
    – Intact TM
    – Cone of light present
    – No bulging or retraction
    – No discharge
    PHYSICAL EXAM
    Ear
    • Normal shape
    • No swelling
    • No erythema
    • No skin lesions
    • No tragal tenderness
    PHYSICAL EXAM
    Face
    • No gross lesions
    • No facial asymmetry
    • No mass
    PHYSICAL EXAM
    Nose
    • External:
    – No tenderness or irregularity
    – No scars or abnormal creases
    – No redness
    – No discharge
    PHYSICAL EXAM
    Anterior Rhinoscopy

    • No congestion
    • No hyperemia
    • No occlusion
    • No mass
    • No discharge
    PHYSICAL EXAM
    Indirect Laryngoscopy

    • Arytenoids not inflamed


    • Good vocal cord
    mobility
    • No masses seen
    PHYSICAL EXAM
    • Posterior Rhinoscopy
    – No mass seen
    – No post nasal drip
    – Patent eustachian tubes
    PHYSICAL EXAM
    Oropharyngeal exam
    – Pink, moist oral mucosa
    – Complete dentition, no dental
    carries
    – Uvula at the midline
    – Grade 4 tonsils, bilateral, no
    exudates
    – Non-hyperemic posterior
    pharyngeal walls
    – No mass
    PHYSICAL EXAM
    Neck
    – No lymphadenopathy
    – Thyroid not palpable
    – Neck circumference: 28cm
    Physical Examination
    Thorax and Lungs: No gross deformities. Thorax is
    symmetric with good expansion. Lungs resonant
    on percussion. Clear breath sounds No crackles,
    wheezes or rhonchi.

    Heart: PMI palpated on the 5th ICS, left MCL.


    Adynamic precordium. No heaves or thrills
    palpated.. Distinct heart sounds with S1>S2 at
    apex and S2>S1 at base, no S3 or S4. Rhythm
    regular. No physiologic splitting. No murmurs.
    Physical Examination
    Abdomen: Non-distended, no scars or striations;
    normoactive bowel sounds, tympanitic, non-tender.
    No palpable organomegaly.

    Genitourinary: No costovertebral angle tenderness.

    Peripheral vascular: Extremities are warm. No varicose


    veins, no edema. Full and equal pulses.

    Musculoskeletal: No gross deformities. Full range of


    motion.
    Physical Examination
    NEUROLOGIC EXAMINATION
    CN I: Grossly intact
    CN II: Pupils equally and briskly reactive to light, 3-2 mm.
    CN III, IV, VI: Full and equal EOMs. No diplopia.
    CN V1, V2, V3: Intact
    CNVII: No facial asymmetry
    CNVIII: Gross hearing intact
    CN IX and X: Midline uvula. Gag (+)
    CN XI: Shoulder shrug and head turn symmetrical.
    CN XII: Tongue midline. No fasciculations
    Sensory: 100% upper and lower extremities, bilateral.
    Motor: 5/5 upper and lower extremities, bilateral.
    Intact cerebellars. Babinski not elicited. No nuchal rigidity
    Salient Features
    • Subjective • Objective
    – Snoring since 3 years old • Enlarged tonsils grade 4 bilateral
    – Witnessed apnea as the • BMI of 25
    patient grew older • Neck circumference of 28cm

    – snorting
    – Hyperactivity
    – Restless sleep
    – History of tonsillitis
    clinically diagnosed 3
    times a year for the last
    3 years
    Impression
    • Chronic Hypertrophic Tonsils; Pediatric
    Obstructive Sleep Apnea, Severe

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