Gacott, Hannah Lei D.

Medicine III-Block 1
Pediatrics Clinic

October 7, 2016
10:30 PM

Source: Mother of the patient

% Reliability: 99%

General Data: C.G, a two years old boy born on March 15, 2014 in Cebu City, Filipino, Roman Catholic and is
currently living with his mother in Daet, Kasambagan, Cebu City, was admitted in Cebu City Medical Central
for the first time on the night of October 3, 2016.

Chief Complaint: Fever

History of Present Illness:

Patient is apparently well until 3 days prior to admission, his mother verbalizes that he had a sudden
onset of fever with a temperature of 39 degree Celsius. His mother gave him tempra but it was not relieved
and continued to rise to 40 degree Celsius. At 4o’clock in the afternoon that day his fever was already
associated with vomiting and weakness thus prompting the mother for a consultation in Chonghua Hospital.
The doctor prescribed paracetamol suppository and told the mother to observe CG for the meantime. 2 days
prior to admission, the patients fever went down to 37 degree Celsius. His mother continued to give him the
prescribed medicine. 1 day prior to admission the patient was getting well according to his mother but in the
evening that day his temperature rose again to 39 degree Celsius. The following day his mother brought him
back to Chonghua. The doctor ordered CBC for CG and the resulting platelet count was below normal for his
age (116). Rashes started to appear on CGs skin thus prompting the mother to admit the patient in Cebu City
Medical Central and not in Chonghua hospital due to money constraint.

Review of Systems:
General: (-) weight change (-) changes in activity level (-) changes in appetite (-) delay in growth
Skin: (-) color change (-) bruising (-) changes in hair and nails (-) rash (-) pigmentation (-) hair loss (-) acne (-
) pruritus
Head: (-) headache (-) dizziness (-) head injury
Eyes: (-) pain (-) tearing (-) loss of vision (-) visual difficulty
Ears: (-) hearing loss (-) ear infection (-) discharges
Nose/sinuses: (-) nasal discharge (-) colds (-) epistaxis (-) obstruction (-) hx of nasal polyps
Mouth/throat: (-) dryness (-) ulcers (-) salivation (sore throuat) (-) gum bleeding (-) hoarseness Neck: (-)
lumps (-) palpable lymph nodes
Pulmonary: (-) cough (-) dyspnea (-) wheezing (-) hemoptysis (-) pleuritic chest pain (-) cyanosis (-)
exposure to inhalants of wielding materials
Cardiovascular: (-) orthopnea (-) easy fatigability (-) fainting spells (-) chest pain (-) dyspnea (-) peripheral
and abdominal edema
Gastrointestinal: (-) dysphagia (-) odynophagia (-) n/v (-) vomiting (-) hematemesis (-) diarrhea (-) food
intolerance (-) pica (-) constipation (-) encopresis (-) early satiety (-) jaundice (-) abdominal edema (-)
abdominal pain (-) passage of worms
Endocrine: (-) breast assymetry (-) breast discharges (-) palpitations (-) cold/heat intolerance (-) polyuria (-)
polydipsia (-) polyphagia
Musculoskeletal: (-) joint pains (-) swelling (-) stiffness (-) limping (-) backache (-) limitation of motion (-)
hx of fractures
Neurologic: (-) fainting (-) seizures/comvulsions (-) weakness or paralysis (+) personality or behavioral
changes (+) mood changes (+) temper outbursts (-) tremors (-) vertigo (-) muscle atrophy (-) sleep problems
Hematologic: (-) pallor (-) bledding manifestation (-) anemia (-) bruising (-) hx transfusion/reaction

Personal History
A. Gestational History: The mother is G2P2(2002), 19 years old during her pregnancy for her 1st
child and 27years old during her pregnancy to C.G. In good health, took folic acid and ferrous
sulfate as a nutritional supplement in her pregnancy. Had UTI and gestational hypertension. No
intake of drugs or roentgen exposure.
B. Birth: CG was delivered term, weighing 6.8klg and through NVSD in Chonghua hospital, attended
by Dr.Quijano.
C. Neonatal History: Had a spontaneous respiration, no cyanosis or pallor and had a good cry. No
jaundice, convulsions, hemorrhage, respiratory difficulties, congenital abnormalities or birth
injury.

Feeding History
Infancy (<2y/o):
i. CG had been breastfeed exclusively more than a year. When he reached 2 his
mother shift to mixed, having nido as the complement milk. His mother can’t
countify how many times she’d breastfeed CG per day but verbalizes “daghan kada
adlaw”.
ii. Complementary foods like rice and fish was first introduced to CG at 1 year old.
Usually given 3x a day.
iii. His usual food intake is rice, fried meat, chicken and fish being his favorite. He is also
eating apple and banana. Five basic food groups are being eaten daily but just in
moderate manner.
iv. Actual caloric intake (ACI) not assessed.
v. Has no food intolerance
vi. CG is taking celine and cherifer as a daily supplement.
vii. His mother is the one taking care of him most of the time but during noon his Aunt
will babysit him for an hour because his mother is selling food in Mabolo
Elementary School.

Development/Behavioral History
According to his mother his first dental eruption was when he was 6 months old and at present he
has a complete set of teeth. He has able to walk when he was at 1 year old. His mother also stated that CG only
new a few words like “mama”, “papa”, “car”, “bird” and that he couldn’t talk and have conversation that much
at his age. He doesn’t have any urinary incontinence. His mother can’t remember when he started toilet
training because most the of the time he was on diaper. His mother stated that CG is always having tantrums
when he reached 2 years old especially when he can’t have what he wants. Most of the time he will bump and
bang his head in his toys when he is irritated and he will grab his hair. He has no phobias, pica, night terrors
or sleep disturbances.

They are living in Daet, Kasambagan, Cebu City. There are a total of 6 people living in their home and
according to his mother 1 member is smoking but also stated that not inside the house. There are also a lot of
smokers in their area according to his mother. Sewers and drainage are somehow okay. Garbage is segregated
properly and their source of water supply is from MCDW. Their drinking water is mineral water. No physical,
sexual, emotional or verbal abuse to the child. His mother is not married to his father and they’re not living
together. His mother’s current partner is 49 years old male who is currently working as a construction
worker. His older brother had a dengue two weeks before CG got sick. There is no history of addiction within
the family but his uncle on his mother side has Down syndrome. Mother is not smoking or taking any drugs,
in physical and mentally good condition. CG is actively playing with his brother and cousins according to his
mother.

Past Illnesses
No history of contagious disease like measles, varicella, mumps or pertussis. No history of
hospitalization and operations. No allergy, eczema, asthma or food and drug sensitivities. He doesn’t have any
history of minor or major injuries.

Immunization History and Tuberculin Test

Has a complete immunization indicated for his age given in their health center.

Family History

Mother is currently 31 years old, in a good state of physical and mental health. His brother is 9 years
old and also has a good state of health.
There no known familial illness or anomalies like tuberculosis, diabetes, syphilis, cancer, epilepsy,
rheumatic fever, allergy, hereditary hematological disorders. Has an uncle who has a Down syndrome.

Environmental History
They are living in Daet, Kasambagan, Cebu City. There are a total of 6 people living in their home and
according to his mother 1 member is smoking but also stated that not inside the house. There are also a lot of
smokers in their area according to his mother. Sewers and drainage are somehow okay. Garbage is segregated
properly and their source of water supply is from MCDW. Their drinking water is mineral water.

Physical Examination
General Survey: No abnormality noted in mental state and sensorium. Not that talkative
and is quite shy. Awake, ambulatory and is in a good nutritional and hydration state and not ill
looking.

Vitals: Has a temperature of 36.2 degree Celsius, RR of 20, CR of 80. Blood pressure not
taken. (BP if >3y.o)

Anthropometric Data:

Weight: 12klg

Length: 94 cm.

Head circumference: 52cm

Skin: Palms are warm. Color is good. No rash, skin lesions, icterus and pallor edema. Skin
turgor is normal. Nails without clubbing and cyanosis.

Head: The skull is normocephalic/atraumatic (NC/AT). Scalp no lesions. Hair is black with
normal quantity, average texture and normal distribution. No presence of parasites. No overlapping
and gaping of suture. There is a normally slightly depressed anterior fontanel. No bruits present
upon auscultation of the skull.
 Face: Symmetrical, no unusual facies, deformities, lumps and bumps. Quite shy expression.

Eyes: No ptosis. Sclerae white, conjunctiva pink, cornea no opacities. Pupils equal, round,
react to light and accommodation.

Ears: 20% of the total length of the ear lobe is located above the imaginary line. No
discharge from ear canal. Intact continuity of ear canal. Light pink in color, intact cone of light and no
presence of effusion or bubbles.

Nose: Nasal mucosa pink, septum midline, no turbinate enlargement, no sinus tenderness.

Throat/Mouth: Lips pink, no humps, ulcers, cracking or scaliness; oral mucosa pink, no
ulcers, patches and nodules. Gums pink, margins normal and no interdental papillae swelling. No
missing teeth. Tongue symmetrical and has normal protrusion. No inflammation of tonsils. Uvula in
the midline. Pharynx without exudate.

Neck: Trachea midline, neck supple, no swelling or inflammation and thyroid non-
palpable.

Chest: Clear and resonant, with good air entry bilaterally and no added sounds. Thorax is
symmetric expansion.

Heart: No abnormal outward pulsations. No palpable heart sounds and murmurs or

extrasounds.