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Case 4

Case 4. Group 4. General Data. Patrick, 2 year old male From Cavite Referred from General Pediatrics Clinic for developmental delay. General Data. History. Born at 43 weeks AOG via SVD (spontaneous vaginal delivery) 29-year old mother G1P1 (1001) Lying-in clinic in Cavite

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Case 4

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  1. Case 4 Group 4

  2. General Data

  3. Patrick, 2 year old male • From Cavite • Referred from General Pediatrics Clinic for developmental delay General Data

  4. History

  5. Born at 43 weeks AOG via SVD (spontaneous vaginal delivery) • 29-year old mother G1P1 (1001) • Lying-in clinic in Cavite • Regular prenatal checkups • At the health center • 3 prenatal UTZ: all normal • (+) excessive vomiting (3rd & 4th months) • (-) history of fever, bleeding, hypertension history

  6. Inadequate contractions during labor • Born limp, cyanotic, meconium-stained rushed to a tertiary hospital • At the tertiary hospital: • Intubated, admitted at ICU (for 2 weeks) • Diagnosis: pneumonia • Stayed for another 2 weeks • After 3 days (1 month of age): cough and difficulty of breathing  brought to PGH history

  7. PGH: • Intubated for 2 days • Treated for pneumonia • After 7 days: discharged • After 1 week (1.5 months of age): readmitted for pneumonia • 3 months of age: • Poor head control • Closed anterior fontanel • Microcephaly history

  8. Subsequent months: • Head lag • Absence of regard • Episode of jerking • Stiffening of extremities (esp. when agitated) • Milestones • 1 year: vocalization • 14 months: Spontaneous smile • 15 months: Appear to listen to sound • 18 months: persistence of stiffening diagnosed as epilepsy history

  9. Respiratory infection: at least once a month • Dyshidrotic eczema: diagnosed at 1 yr. of age other medical problems

  10. (-) similar neurodevelopmental illness • (+) Asthma: mother and materal aunt • (+) HPN: maternal grandmother familyhistory

  11. Father • 29 years old • Security guard • High school graduate • Mother • 30 years old • Housewife • High school graduate • Brother • 8 years old • Grade 3 student personal/social history

  12. 0-3 months: breastfed • Then gvenBonna at 1:2 dilution • (+) regurgitation of milk • 6 months: given cereal  thrusted out  ricewater (“am”) + milk instead • Currently on Bonamil + am • 6oz. Nine times/day • Slightly thickened solution nutrition history

  13. 0-3 months: breastfed • Then gvenBonna at 1:2 dilution • (+) regurgitation of milk • 6 months: given cereal  thrusted out  ricewater (“am”) + milk instead • Currently on Bonamil + am • 6oz. Nine times/day • Slightly thickened solution nutrition history

  14. Physical Exam

  15. physical exam

  16. physical exam

  17. Neurologic Exam

  18. neurologic exam

  19. neurologic exam

  20. Differentials

  21. Cerebral Palsy

  22. Down’s Syndrome

  23. Infantile Multiple Sclerosis

  24. Infantile Parkinsonism

  25. Muscular Dystrophies

  26. Congenital Malformations

  27. Metabolic Diseases

  28. Metabolic Diseases

  29. Spinal Cord Lesions

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