1 / 16

General Data

General Data. 2 yr old female from San Pablo, Laguna Sought consult last June 8, 2009 CC: FEVER. History of Present Illness. 7 days PTA  O n and off fever, Tmax 39C temporarily relieved after intake of Paracetamol .

deiter
Download Presentation

General Data

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. General Data • 2 yr old female from San Pablo, Laguna • Sought consult last June 8, 2009 • CC: FEVER

  2. History of Present Illness • 7 days PTA On and off fever, Tmax 39C temporarily relieved after intake of Paracetamol. • 6 days PTA Appearance of maculopapular rashes at the head progressing to the abdomen and to the extremities. Fever persisted. • 5 days PTADry fissured lips. Rashes and fever persisted.

  3. History of Present Illness • 4 days PTA  Signs and symptoms persisted. • 3 days PTA  Patient was brought to Immaculate Concepcion Hospital in San Pablo, Laguna. Assesment was T/C Systemic Viral Infection and was given Co-trimoxazole, Paracetamol, and ascorbic acid. Mother noted edema of the finger tips and desquamation of the skin at the buttocks area with persistence of fever. Hence, transferred to PGH and subsequently admitted.

  4. Review of Systems • (-) abdominal pain, (-) seizure, (-) chest pain, (-) diarrhea, (-) cough, (-) nausea, (-) colds, (-) vomiting, (-) conjunctival suffusion

  5. Past Medical History • January 2009 – Pneumonia at Immaculate Concepcion Hospital

  6. Birth and Maternal History • Born FT to a then 24 year old G2P1(1001) mother via SVD delivered at home by a midwife. Mother had regular PNCU c/o local health center with intake of MVT and FeSO4. No fetomaternal complications.

  7. Family History • (+) DM – maternal side

  8. Personal and Social History • Mother is a 26 year old housewife. • Father is a 28 year old security guard. • Patient is the second child in a family of 2 kids. • Older child is 5 y/o male, healthy.

  9. Immunization History • (+) BCG • (+) OPV3 • (+) DPT3 • (+) Hepa B3 • (+) Measles

  10. Recommended Immunizations • Birth: BCG, Hepa B • 6 weeks: DPT1, OPV1, Hepa B • 10 weeks: DPT2, OPV2, (Hepa B*) • 14 weeks: DPT3, OPV3,Hepa B • 6 months (and yearly thereafter): Influenza • 9 months: measles • 12 months: MMR, Varicella, Hepa A (2 doses 6 months apart)

  11. Recommended Immunizations • The patient should also be getting yearly Influenza shots, as well as MMR, Varicella, and Hepa A shots. • MMR should be taken at 12 mos; the 2nd dose should be taken through 4-6 years (can be taken before 4 mos, provided at least 28 days have elapsed since the 1st dose

  12. Recommended Immunizations • Varicella: min age is 12 mos; 2nd dose should be taken from 4-6 yrs (can be taken before 4 yrs provided at least 3 mos have elapsed); min interval bet doses is 3 mos for children aged 12 mos to 12 years • Hepa A: min age is 12 mos; administer 2 doses at least 6 mos apart

  13. Nutritional Status *Patient is of normal weight for her age

  14. Patient’s Developmental Stage: at par with her age (2 years old) Developmental milestones of a 2 year old child Physical Development -Child reaches about ½ of his maximum adult height. -90% of adult head circumference is reached, with just an additional of 5 cm gain for the next few years. Motor Development: Runs well -walks up and down the stairs, one step at a time -climbs on furnitures -jumps

  15. Adaptive Development -Makes tower of 7 cubes -Scribbles in circular pattern -Imitates horizontal strokes -Folds paper once, imitatively • Cognitive Development -Object permanence -Improved problem solving skills, better understands cause and effect -Language: -Puts 3 words together into simple sentences(subject, verb, object) -Vocabulary comprises of about 50-100 words -Can understand and follow 2-step commands

  16. Socio-Emotional Development -Often tells about his immediate experiences -self awareness and internalized standards of behavior sfirst appears at this age Self-Help Skills -Handles spoon well -Helps in undressing Source: Nelson Textbook of Pediatrics

More Related