FAR EASTERN UNIVERSITY DR.

NICANOR REYES MEDICAL FOUNDATION

Regalado Ave., cor. Dahlia St., West Fairview, Quezon City, 1118
Tel. No.: 427-0213
DEPARTMENT OF CHILD HEALTH

PEDIATRIC HISTORY

September 28, 2014 Informant: Mother

Reliability: 85%

GENERAL DATA: Cruz, Kent Arquee, 3 year old, male, Filipino, Catholic, born July 31, 2011 in Norzagaray, Bulacan, currently
residing at #143 Marlane Minuyan, Norzagaray, Bulacan, admitted for the first time in FEU NRMF Medical Center last
September 28, 2014.

CHIEF COMPLAINT: abdominal pain

HISTORY OF PRESENT ILLNESS:

The history of present illness started 4 days prior to admission when patient had right lower quadrant pain, not
precipitated by food or movement, non-radiating, moderate to severe, occurring intermittently throughout the day. It is
accompanied by 3 episodes of vomiting of pink tinged previously ingested food, non billous; decreased activity preferring to lie
down in bed most of the day, and decreased in appetite from approximately 1 cup to 3 tablespoons of food. Patient also did not
have any bowel movement during the day. Consult was done at a public hospital in Bulacan where patient was diagnosed with
Urinary Tract infection and was put under observation at the Emergency Room. He was given unrecalled antibiotic, pain
relievers and antihelminthic of unrecalled dose, amount and frequency. No relief was noted. Later that day, patient had
undocumented low grade fever and had an episode of seizures described as stiffening of upper and lower extremities with
upward rolling of eyeballs. He was given Paracetamol of unrecalled dose 5ml and tepid sponge bath as done. He was then
subsequently admitted. Diagnostics requested were CBC and Urinalysis. CBC normal results while Urinalysis showed presence of
pus cells in the urine.
Three days prior to admission, still with above signs and symptoms, abdominal pain now generalized with increasing
frequency and loss of appetite. Patient vomited for 3-5 times during the day of previously ingested food, non billous. He was
still given with unrecalled antibiotics, antihelminthic and pain reliever with no relief. Patient still has no bowel movement.
Two days prior to admission, still with above signs and symptoms, patient had bowel movement. First episode was
with reddish brown formed but with some watery non mucoid stool. The second episode of bowel movement was described as
dark red jelly like stool. Patient had subsequent bowel movement every two hours during the day, described as loose, watery,
non mucoid, yellowish-brownish in color. Every subsequent episode was accompanied by increasing severity of abdominal pain.
Relattives also noticed undocumented increase in abdominal girth. He was still given with unrecalled antibiotics, antihelminthic
and pain reliever with no relief. HBT ultrasound was done and showed normal liver, gallbladder and biliary tree.
Signs and symptoms persisted until one day prior to admission, parent opted to transfer at a private hospital. He was
referred with a diagnosis of Acute Gastroenteritis. Due to lack of available rooms, they asked for referral to transfer to another
hospital. No labs, medications or interventions was done. They then transferred to a childrens hospital but was then referred
to another public hospital due to lack of available rooms. No interventions, labs done or medications given.
Few hours prior to admission, abdominal pain was said to have increased in severity with 3 episodes of billous
vomiting, patient was transferred to a public tertiary hospital. Coagulation Report, blood chemistry, blood typing and CBC with
PC. Blood chemistry showed hyponatremia and hypokalemia with decreased BUN and creatinine levels. He was diagnosed with
complete gut obstruction and advised for operation. However, due to lack of available rooms, relatives was advised to transfer
to another hospital. NGT was inserted and he was transferred to this institution and was subsequently admitted.
At the ER, patient had severe abdominal pain and billous vomiting. Vital signs were BP: 160/100 mmHg, CR: 120 per
minute, RR: 28 per minute, T: 37.5C. Upon physical exam, pertinent findings were NGT inserted on left nostril, globular
abdomen, tense, abdominal circumference of 51cm, hypoactive bowel sounds, with generalized tenderness. Abdominal x-ray
and whole abdomen ultrasound were done. Xray showed consider small bowel obstruction (cannot rule out intussuception in
origin). Whole Abdominal Ultrasound showed urinary bladder sediments (inflammatory debris?) and incidental note of gassy
and hyperperistaltic dilated small bowel loops with thickening of the interserosal spaces and valvulae conniventes suggestive of
small bowel obstruction.

PRENATAL HISTORY:
Patient was born to 20 year old G1P1 (1001) via spontaneous vaginal delivery, term. Maternal Blood type was O+.
Paternal Blood type is unknown. HbsAg was unknown. Mother claimed to have started prenatal check up during her 5th month
of pregnacy and only had 3 prenatal check ups since then. She claims to have regular intake of multivitamins and prenatal milk.
No intake of ferrous sulfate,folic acid and calcium. She has history of UTI during her 5th month of pregnancy with intake of
unrecalled antibiotics whoch she took for 10 days. No repeat urinalysis was dpone. She denies exposure to x-ray or chemicals,
intake of alcohol, smoking, trauma or accidents. She had no history of hypertension, diabetes mellitus, asthma, or vaginal
bleeding during pregnancy. She had no episode of fever with cough and coldsduring her pregnancy.

NATAL HISTORY:
Patient was born via vaginal spontaneous delivery, term, delivered at home and was attended by a nurse. She was
then brought to a nearby hospital and was admitted. Patient was said to have spontaneous breathing with no cyanosis,
bleeding or jaundice noted.

POST NATAL HISTORY:

Patient stayed at the hospital for a day. No bleeding, cyanosis or vomiting was noted post natally. Patient was said
have yellowish discoloration few days after hospital discharged and was managed through sun exposure.

NUTRITIONAL HISTORY:
Patient was breastfed from birth to present. Mixed feeding was initiated when he was 1 year old, starting with
Progress formula milk with 1:1 dilution, consuming about 1 bottle per day. Patient was then shifted to Bona with 1:1 dilution
consuming 1 bottle per day. Solid foods was started around 6 months. No food intolerance or allergies was noted.

IMMUNIZATION HISTORY:
Patient had the following immunizations:

BCG 1 dose Hospital

Hepa B 3 dose Health center
OPV 3 doses Health Center
DPT 3 doses Health Center
Measles 1 dose Health Center

PAST MEDICAL HISTORY:

Patient is non asthmatic, no history of accidents, surgery, previous surgeries & blood transfusion. Patient was
diagnosed with PPTB at a private clinic when he was around 1 year old. He only took the PPTB treatment for one month but
discontinued due to parents anxiety of giving medications at a young age. In 2013, patient was admitted due to diarrhea with
incidental diagnosis of Primary Complex but no treatment was given. Last August 2014, patient was diagnosed with Primary
Pulmonary Tuberculosis and is currently on his 1st month of treatment- ongoing.

FAMILY HISTORY:
Father: 24, cement company employee, apparently well
Mother: 23, student, apparently well
Has history of bronchial asthma, maternal grandmother.
No other heredofamilial diseases such as hypertension, diabetes mellitus, metabolic disorders, cancer, heart disease,
kidney disease, liver disease, thyroid disease.
PERSONAL AND SOCIAL HISTORY:
The patient lives in a well-lit, well-ventilated 2-storey house with 5 household members. Primary caregiver is mother.
Electricity was provided by Meralco, drinking water is mineral water, utility water by NAWASA and garbage collection was 1-2
times a week. He prefers sweets but mother claims that patient usually has good appetite. Grandfather is a smoker.

PHYSICAL EXAMINATION UPON ADMISSION:

General Survey: patient is conscious, coherent, not in distress, adequately hydrated with the following vital signs:
BP: 100/60 mmHg CR: 102/min RR:26/min Temp: 36.8oC
Wt: 13 kg Length: 95.5cm IBW: 14kg BMI: 14.25kg/m2 TCR: 1400kcal/day
TFR: 1820kcal/day

HEENT: pink palpebral conjunctiva, white sclera, pink turbinates, brownish material partially occluding the right ear canal, moist
lips and buccal mucosa, pink pharyngeal walls
Neck: supple, no palpable lymph nodes
Chest/Lungs: symmetrical chest expansion, no retractions, clear breath sounds, good air entry
Heart: adynamic precordium, tachycardic, regular rhythm, no murmur
Abdomen: globular, abdominal circumference of 50.5cm, tense, hypoactive bowel sound, hypertympanitic on percussion, (+)
generalized tenderness
Extremities: no gross deformities, full and equal pulses, CRT <2 seconds
Skin: no active dermatoses

Neurologic Examination:
Cerebrum: conscious, coherent, oriented to time, place and person
Cerebellum: No dysdiadokinesia
CRANIAL NERVES:
I: can smell coffee
II: 2-3 mm diameter pupils equally round and reactive to light and accommodation
III, IV, VI: intact extraocular muscle movements
V: can clench teeth
VII: no facial asymmetry
VIII: gross hearing intact
IX and X: uvula is at the midline
XI: can move head from side to side and shrug shoulders against resistance
XII: tongue is at the midline

MOTOR SENSORY DTR

5/5 5/5 100% 100% ++ ++
5/5 5/5 100% 100% ++ ++

Meningeal signs: No nuchal rigidity, (-) Kernig, (-) Brudzinski

Pathologic reflexes: Babinski (-) Oppenheim (-)

ADMITTING DIAGNOSIS: Small Bowel Obstruction secondary to intussusception vs congenital band

Plan:
Please admit to the service of Dr. Banez/Sarmiento/Pinon/Genuino
Please secure consent for admission and management
NPO temporarily
IVF: Plain LR to run at 65cc/hr due 8AM
For complete blood count with platelet count
Start Ampicillin 500mg TSIV q6 ( ) ANST (TD: 153.8mg/kg/day)
Start Gentamicin 33mg TSIV q8 ( ) ANST (TD: 7.6mg/kg/day)
Start Metronidazole 98mg TSIV q6 ( ) ANST (TD 30.1mg/kg/day)
Insert NGT
Refer to Surgery for co-management
Weigh patient now then daily and record
Monitor intake and output every shift and record
Watch out for progression of abdominal pain

Dr. Bautista/A. Sarmiento/K. Sarmiento/Valenzuela/PGI Agustin/JIIC Ferrer