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1. ??? Group 1: RxMen Angustia ★ Ayes ★ Chan ★ Co Garcia ★ Macapinlac ★Tumibay ★Vega

2. INTRODUCTION

3. Introduction • Purpose of the presentation • Impact of illness to the patient and family • Coping mechanism • Family dynamics • Social resources

4. General Data • AP • 4 mos./Male • Filipino • Roman Catholic • Residing in San Miguel, Pasig City • Informant: Mother, Father, and Paternal Grandparents • Reliability: 70% • Admitted at PCGH on December 3, 2010

5. Chief Complaint • Fever (2 days)

6. History of Present Illness • 3 weeks PTA • intermittent cough, productive of whitish phlegm • No associated signs and symptoms • consult at a private clinic • Ambroxol (unrecalled dosage)  No relief • Amoxicillin 6.75 mg  No relief

7. History of Present Illness • 2 weeks PTA • persistence of symptoms • consult at a private clinic • Carbocisteine • Co-trimoxazole (unrecalled dosage) • Phenylpropanolamine (Disudrin) 0.5 ml QID • Phenylephrine HCl, chlorphenamine (Neozep) 0.5 ml QID • No relief

8. History of Present Illness • 2 days PTA • persistence of symptoms • (+) undocumented fever • (+) Difficulty of breathing • No consult done • Parents self-medicated patient with Paracetamol drops 8.45 mg/kg/dose

9. History of Present Illness • Morning PTA • persistence of symptoms • (+) rhinorrhea, productive of yellowish-green mucous • (+) vomiting milk and phlegm (about 4 oz) • Consult at health center • Cephalexin 32.43 mg/kg/day • Paracetamol 8.45 mg/kg/dose • Increase in fever • (+) cyanosis of distal extremities PCGH ER

10. Review of Systems • Constitutional: no weight loss, no weakness • Integument: (+) rashes (diaper), no changes in color • Respiratory: no hemoptysis • Gastrointestinal: no changes in bowel movement • Genitourinary: no frequency

11. Past Medical History • no previous hospitalization • no previous operations • no history of trauma

12. Family Medical History • Liver disease, Tuberculosis - Maternal side • Breast cancer - Paternal side • (-) Asthma • (-) DM • (-) Hypertension, cardiac disease

13. Developmental History • patient is a 4 mo., male • (+) grasps object placed in hand • (+) moves head toward sound • (+) reaches for objects • (+) chews • (+) roll over • (-) chest up, arm support

14. Immunization History • BCG - 1 dose • OPV - 1 dose • Hepa B - 1 dose • No HiB

15. Birth History • Born Full Term to a 17 year old G1P1, delivered via Normal Spontaneous Delivery with birth weight 3.6 kg, at a lying-in clinic, attended by midwife, (-) perinatal/neonatal complications

16. Nutritional History • Breast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day) • No known food allergy

17. Genogram (12/30/10) I 43 49 48 46 II 18 24 21 13 16 14 15 11 20 18 III 4 mos.

18. Personal Social history • Only Child • Mother - 18 y/o not employed • Father - 20 y/o factory worker • Parents not married • Families are not on good terms

19. Environmental history • Patient does not stay permanently in one household. He is shuttled from the mother’s household to the father’s household and vice versa • Lives in a 1 story wooden house near the streets with 2 bedrooms. • The house is well ventilated and well lighted.

20. Environmental history • Their water supply comes from Manila Waters. • Drinking water of the patient was previously Wilkins, but now the water comes from a refill station • Garbage is collected every day.

21. Physical Examination • General Survey: • Conscious, alert, in mild respiratory distress, well-nourished • Vital signs: • HR 165, RR 38, Temp 40.5oC • Anthropometrics: • Length 59 cm (<3rd percentile) • weight 7.4 kg (50-85th percentile for age, >97th percentile for length) • HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm

22. Physical Examination • Skin: • normal skin color, good turgor (CRT<2 sec), flushed skin • (+) diaper rash, inguinal area extending to buttocks, (-) lesions, flushed skin • HEENT and neck: • flat, open anterior fontanel; closed posterior fontanel • Normal hair distribution, (-) masses/depressions • anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm ERTL • (-) ear deformities, (-) discharge, (+) intact tympanic membrane, (+) cone of light • (-) nasal deformities, (+) rhinorrhea, yellow-green discharge slightly dried • (-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy, supple neck, flat neck veins

23. Physical Examination • Heart: • adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm • (-) murmurs, good S1/S2 • Lungs: • (-) scars or masses, (+) intercostal/subcostal retractions • symmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields

24. Physical Examination • Abdomen: • globular abdomen, (-) masses or scars • Normoactive bowel sounds • tympanitic abdomen • (-) tenderness, (-) organomegaly • Genital exam: • grossly male, (-) deformities • Descended testes

25. Physical Examination • Extremities: • full and equal pulses, (-) edema, (-) cyanosis

26. Neurologic Examination • Cranial Nerves: • CN I - not tested • CN II – 3-4 mm equally reactive to light • CN III, IV, VI – intact EOMs • CN V – reacts to facial sensory stimulation • CN VII – no facial asymmetry, able to smile and cry • CN VIII – responds to sound and verbal stimuli • CN IX, X – able to feed, good suck • CN XI – able to turn head from side to side • CN XII – tongue midline

27. Neurologic Examination • Sensory: responds to stimuli (light touch) • Motor: good muscle tone and strength • Reflexes • (+) Babinski • (+) palmar grasp • (-) rooting • (-) moro • (-) tonic neck

28. Salient Features • 4 mo./M • fever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomiting • medications given afforded no relief • on PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields

29. Admitting Diagnosis • Pediatric Community Acquired Pneumonia, Category C • (+) fever, difficulty of breathing, cyanosis, cough and colds • PLUS findings on PE: (+) tachycardia, (+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles