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PHARMACOLOGY CONFERENCE

PHARMACOLOGY CONFERENCE. Mendoza, Donne; Mendoza, Gracielle ; Mendoza, Trisha; Mindanao, Malvin Ace. MNL 4 months November 18, 2010 114 Hansens St. East Tapinac, Olongapo Catholic Filipino Informant: Parents Reliability: Good. ULCER OVER THE LEFT LABIA. Chief complaint:.

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PHARMACOLOGY CONFERENCE

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  1. PHARMACOLOGYCONFERENCE Mendoza, Donne; Mendoza, Gracielle; Mendoza, Trisha; Mindanao, Malvin Ace

  2. MNL • 4 months • November 18, 2010 • 114 Hansens St. East Tapinac, Olongapo • Catholic • Filipino • Informant: Parents • Reliability: Good

  3. ULCER OVER THE LEFT LABIA Chief complaint:

  4. GESTATIONAL HISTORY • born to a 31 year old production worker G2P1 (1001) married to a 26 year old businessman. • took 7 tablets of Aspirin of unrecalled dosage when she was 5 days delayed but stopped when she tested positive for pregnancy. • regular prenatal check-up: 1 month AOG at a local hospital with a total of 10 visits. • She only took folic acid as supplement. • She did not smoke, nor drink alcoholic beverages and was not exposed to viral exanthems nor radiation. • Ultrasound at 1st and 3rd week and a congenital scan showed normal results. • HBsAg screening was negative, no OGCT done.

  5. BIRTH HISTORY • Born at 38-39 weeks AOG • Live, singleton, delivered via LTCS under spinal anesthesia • APGAR score 8-9 • Birth weight = 3.2 kg • Immediately roomed-in • Physical examination: • Hemangioma over the left labia • (+) sacral dimpling • Polydactyly on both hands • (+) preauricular skin tag on the right ear

  6. (+) rashes on the region of the hemangioma (+) change in size No other symptoms noted Consult with a Pediatrician - prescribed unrecalled ointment  no resolution HISTORY OF PRESENT ILLNESS 3 weeks PTA (+) ulceration of hemangioma Consult with a Pediatrician - prescribed Fusidic acid (1 week)  no resolution - Fusidic acid 2% and Cloxacillin 2 weeks PTA

  7. HISTORY OF PRESENT ILLNESS (+) pus on hemangioma Consult with a surgeon who suggested consult at USTH 1 week PTA ADMISSION

  8. REVIEW OF SYSTEMS • Cutaneous: (-) rashes, (-) pruritus • HEENT: (-) nasoaural discharge, (-) eye discharge, (-) sore throat • Respiratory: (-) dyspnea, (-) chest pain • Cardiovascular: (-) palpitations, (-) cyanosis, (-) easy fatigability • Gastrointestinal: SEE HPI

  9. REVIEW OF SYSTEMS • Genitourinary: (-) dysuria (-) hematuria • Musculoskeletal: (-) weakness, (-)swelling • Hematopoietic: (-) easy bruisability, (-) bleeding • Endocrine: (-) polyuria, polydipsia, polyphagia • Nervous/Behavior: (-) headache, (-) seizures, (-) loss of consciousness

  10. FEEDING HISTORY • Not breastfed • Milk formula: Nan-one with 1:1 dilution • given 6x/day • total of 709.7 mL (24oz) per day • Total caloric value: 475 kcal/day

  11. DEVELOPMENTAL MILESTONES DEVELOPMENT/BEHAVIORAL HISTORY • Gross motor • With good head control on sitting position • Begins to reach for toys symmetrically • Fine motor • Midline regard • Language • Coos • Personal Social • Laughs

  12. IMMUNIZATIONS

  13. PAST MEDICAL HISTORY 2 months: Bronchitis, given Salbutamol nebulization No previous hospitalizations or surgeries

  14. FAMILY HISTORY (+) HPN, DM, Bronchial asthma (-) cancer, tuberculosis

  15. FAMILY PROFILE

  16. PERSONAL, SOCIOECONIMIC AND ENVIRONMENTAL HISTORY Concrete house with both parents, mother is the primary caregiver Well-ventilated, well-lit Drinking water is distilled Garbage is not segregated but collected twice a week No nearby factories, with cats

  17. PHYSICAL EXAMINATION Alert, awake, not in cardiorespiratory distress VS: CR 142 bpm RR 36 cpm T 36.9 C Wt 5 kg. (z= 0) Lt. 64 cm (z= -2) BMI 13.4 (z= below -1)

  18. PHYSICAL EXAMINATION Warm, smooth skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclerae (+) Preauricular skin tag, AD, no tragal tenderness, non-hyperemic EAC, (+) retained cerumen, AU, intact tympanic membrane, no aural discharge AU Midline septum, turbinates not congested, no nasal discharge Moist buccal mucosa, non-hyperemic posterior pharyngeal wall

  19. PHYSICAL EXAMINATION Supple neck, no palpable cervical lymphadenopathy Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, apex beat 4th LICS MCL, no heaves, thrills, murmurs Globular abdomen, AC = 38cm, NABS, soft, non- tender, no mass palpated

  20. PHYSICAL EXAMINATION Pulses full and equal, no cyanosis, no edema, (+) polydactyly both hands, (+) sacral dimpling (+) hemangioma on the left labia, measuring 4 x 3 cm with an ulcerating lesion measuring 2 x 1 cm with whitish discharge DRE: tight sphincteric tone, no tenderness, no masses, brown fecal material on tactating finger, non-blood tinged

  21. NEUROLOGIC EXAMINATION Mental Status: alert, awake Cranial Nerves are intact: intact EOM; no ptosis; no jaw deviation; smiles, open and close his eyes, no facial asymmetry; midline uvula, no tongue atrophy, no fasciculations, no deviation No Babinski, no nuchal rigidity No motor or sensory deficit

  22. SALIENT FEATURES • POSITIVE • NEGATIVE

  23. APPROACH TO DIAGNOSIS

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