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General Data

General Data. P.A. 4y/o, F Quezon City Roman Catholic/Filipino Date of admission: 4/29/10 Informant: mother Reliability: good. Chief complaint. FACIAL EDEMA. History of Present Illness. (+) fever (undocumented) (+) sorethroat (+) rashes ( red, pruritic patches?)

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General Data

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  1. General Data • P.A. • 4y/o, F • Quezon City • Roman Catholic/Filipino • Date of admission: 4/29/10 • Informant: mother • Reliability: good

  2. Chief complaint FACIAL EDEMA

  3. History of Present Illness • (+) fever (undocumented) • (+) sorethroat • (+) rashes (red, pruritic patches?) • no cough and colds • Consult at local clinic and diagnosed with tonsillopharyngitis • Given Co-amoxiclav (unrecalled dosage) until lysis of fever (4 days) 18 days PTA

  4. History of Present Illness • Facial and periorbital edema • Abdominal enlargement • Difficulty of breathing • Tea-colored urine • ↓ urine output • no edema of extremities • No medications taken • No consultation done 3 days PTA

  5. History of Present Illness • Consult at a local clinic • Urinalysis, BUN, Creatinine, ESR • Persistence of symptoms 2 days PTA 1 day PTA Admission

  6. Review of Systems • General: (-) weight loss, (-) loss of appetite • Cutaneous: (-) pigmentation, (-) hair loss, (-) pruritus. • HEENT: (+) headache, (-) visual difficulties, (-) lacrimation, (-) aural discharge, (-) epistaxis, (-) toothache. • Gastrointestinal: (-) vomiting, (-) diarrhea, (-) constipation, (+) passage of worms, (+) abdominal pain, (-) jaundice, (-) food intolerance. • Genitourinary: urine yellow in color, (-) burning sensation, (-) discharge

  7. Review of Systems • Endocrine: (-) palpitation, (-) cold or heat intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia. • Nervous/Behavioral: (-) tremors, (-) convulsions, (-) weakness or paralysis, (-) mental deterioration, (-) mood changes, (-) hallucinations. • Musculoskeletal: (-) swelling of bones/joints, (-) stiffness, (-) limping. • Hematology: (-) pallor, (-) bleeding manifestations, (-) easy bruisability.

  8. Feeding History • Picky eater, dislikes vegetables • ACI • 24 hour food recall • Breakfast: 1 cup soup, 1 glass milk • Lunch: ½ cup rice, 1 pc chicken breast • Dinner: ½ cup rice, 1 pc chicken breast, mango • Snack: 1 cup noodles with egg

  9. Personal History Developmental history • hops on one foot • Copies a drawing of a cross and circle • Counts to ten • Plays cooperatively • Goes to the toilet alone

  10. Past Illnesses • (+) bronchopneumonia (2006) • (+) mumps (unrecalled date) • (-) surgeries or blood transfusions • (-) known allergies • (-) asthma

  11. Immunization History • BCG • Hep B x 3 doses • DTP x 3 doses • OPV x 3 doses • Measles • BOOSTER DOSE?? At a local health center in Quezon City

  12. Family History • (+) HPN – father • (-) Renal disease • (-) DM • (-) PTB • (-) Asthma • (-) CA

  13. Family History

  14. Socioeconomic and Environmental History • Lives with parents and younger sibling in a 1-floor, cemented apartment like complex. • Well-lit but not well-ventilated (no windows, 1 door) • 2x/week garbage collection with no segregation • There are no factories nearby, but there is exposure to vehicular exhaust • Purified drinking water • No pets

  15. PE on Admission • General Description: Patient is awake, coherent, ambulatory, not in cardiorespiratory distress, well-nourished, and well-hydrated. • Vital Signs: pulse rate 120 beats/min; respiratory rate 36 cycles/min; temperature 36.5° C; blood pressure 110/70 mm Hg. • Anthropometric Measurements: wt 17 kg (z score below 0), ht 104 cm (z score below 0), AC: 52.5cm. • Skin: warm and moist, (-) jaundice, (-) edema, (-) loss of tissue turgor. • Head, Eyes, Ears, Nose: (-) swelling, (-) discharge, tympanic membrane intact, pink, flat, cone of light present, (-) effusion; nasal septum midline, (-) sinus tenderness, (+) facial edema, (+) impacted cerumen. • Mouth and Throat: moist buccalmucosa, pink lips, (-) dryness, (-) gum bleeding; tongue pink, (-) dryness, non -hyperemic posterior pharyngeal area, grade 3 tonsillar enlargement, (-) exudates. • Neck:supple neck, (-) palpable cervical lymph nodes.

  16. PE on Admission • Lungs: symmetrical chest expansions, normal vocal fremiti, lung fields resonant on percussion, decrease breath sounds on anterior chest, fine crackles on the right base of lung, and occasional wheezes. • Heart: dynamic precordium, (-) thrills, (-) heaves, apex beat 4th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, S2 splits on inspiration, (-) murmurs, • Abdomen: globular, soft, nontender (-) prominent vessels, (-) striae, (-) pulsations, (-) paradoxic movements with respect to respiration, normoactive bowel sounds (10/min), (-) splenomegaly, (+) costovertebral angle tenderness, (+) fluid wave, (+) shifting dullness, (+) umbilical hernia. • Extremities: (-) pain, (-) swelling, (-) clubbing. • Spine: (-) scoliosis, (-) tenderness.

  17. Neurologic Examination • Conscious, coherent, follows commands, GCS15 • Cranial nerves intact: Pupil size 2-3 mm equally reactive to light; no ptosis (OU) intact EOM movements, can move face and shrug shoulders side by side. • No abnormal movements, normal gait • MMT 5/5 on all extremity, DTR (++) on all extremities • No sensory deficit • No involuntary movement, no spasticity, no atrophy • No nuchal rigidity, no Babinski, no Kernig’s, no Brudzinski

  18. Salient Features • 4 year old female • Chief complaint of facial edema • Abdominal enlargement • Tea-colored urine • ↓ urine output • Fluid wave • Shifting dullness • 2 ½ week history of tonsillopharyngitis

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