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College Of Medicine

DEPARTMENT OF PEDIATRICS

Historian: Bam , Deepak B.

GENERAL DATA:

This is the case of AJ,3 months old (DOB: 11/13/2017), male, presently
residing at Sta. Maria, Bonuan, Pangasinan, Roman Catholic, Filipino, informant
is the mother ( m. aquinis), with good reliability (90%), admitted for the first time on
January 21, 2018, at 5:00 PM at Region 1 Medical Center.

CHIEF COMPLAINT:

“Sudden onset of irregular movement of the body as verbalized by the

mother”

HISTORY OF PRESENT ILLNESS:

1 week PTA: patient experienced undocumented fever , seizure thus, sought
consult at PPH , patient was admitted at PPH and was given
medication ,
2- days PTA: patients has seizure of fever, no consultation took amoxicillin,

1-day PTA: patient experienced sudden onset of seizure with loss of

consciousness, uprolling eyes with facial flushing which last for 5
minutes of duration with no history of fever, no vomiting , no foathing
of saliva, , no cough and colds, patients was consult at Villiaflor.

FHPTA: patients experience persisted of seizure,loss of convulsion, loss of

consciousness, up rolling of eyes ,stretching of body and vomiting
mucoid , whitish around 20 ml which is no projectile, and then patient
was refer to Region 1 medical center for admission .

PAST MEDICAL HISTORY:

Patient was admitted at PPH for fever and seizure, on jan ,29 2018
No other history of medical illness and No surgery has done , No trauma history.
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IMMUNIZATION:

Patient was immunized with BCG ,1st and 2nd dosage of Hepa B, and 1st
dosage of DTaP.

BIRTH HISTORY:

Patient was delivered full term via Normal Spontaneous Delivery at,
Pangasinan. Birth weight of 2.7kg, length, and APGAR score unrecalled. Patient
was born to a 37-year-old, G7P7 (7007), AOG via Last Menstrual Period unrecalled.
mother claims she had 6 times prenatal check-ups, with no history of Asthma,
Diabetes Mellitus, and Hypertension etc. Also with no episode of vaginal bleeding,
spotting, dysuria, and hypogastric pain during course of pregnancy.

MATERNAL HISTORY:

The mother experienced the usual signs and symptoms of pregnancy such
as cessation of menses, urinary frequency, nausea and vomiting. Self-pregnancy
test was, done. obstetrical consultation was done. multivitamins were taken.
mother denies that there is no history of trauma, accidents, illness, or any exposure
to radiation or chemicals during pregnancy with no history of fever, hypertensive
episodes, hypogastric pain, no alcohol intake, no smoking no drugs used during
pregnancy period .

DEVELPMENTAL HISTORY :-

Motor Skills

 Supports head and upper body when on stomach

 Stretches out legs and kick when on stomach or back

 Opens and shut hands

 Brings hands to mouth

 Grabs and shakes hand toys

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 Swipes and bats at dangling objects

 Pushes down legs when on a flat surface

 Follows moving objects with eyes

 Turning their head to face the stimulus

Language Skills

 Makes cooing sounds

Social/Emotional Skills

 Smiles at familiar faces

 Enjoys playing with other people

FEEDING HISTORY:

Patient was breast-fed until 1-months old. Introduction of formula feeding

Nestogen brand milk started on his 2rd month 4 scoops, 4 times a day till now. No
known food related allergies as well as feeding difficulties were noted.

FAMILY HISTORY : mother has asthma , and his elder sister has asthma , no
other known heritable diseases in family like cancer , hypertension ,epilepsy etc.

SOCIAL HISTORY : he stay with his parents and siblings he is 7th child of the
family, total member of 10 , who stay in concrete house of 4 well ventilated bed
room , one separate toilet and separate Kitchen ,her mother is house wife and
father is a businessman . as for the drinking water they get it from tap /NAWASA,
for their garbage disposal they burn in their backyard.

REVIEW OF SYSTEM:
GENERAL
(+) Weakness (-) malaise, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-)
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sweats
SKIN
(-) rash, (-) pruritus, (-) pigmentation, (-) lumps, (-) sores, (-) dryness, (-) change in
hair & nails
HEENT
HEAD
(-) headache, (-) dizziness, (-) light headedness
EYES
(-) vision, (-) glasses or contact lenses, (-) pain, (-) redness, (-) itching, (-) excessive
tearing,
(-) double vision, (-) blurred vision, (-) spots, (-) specks, (-) flashing lights, (-)
glaucoma, (-) cataracts

EARS
(-) hearing, (-) tinnitus, (-) vertigo, (-) earaches, (-) discharge
(-) pain,
NOSE&SINUSES
(-) colds, (-) discharge, (-) itching, (-) dryness, (-) nosebleeds, (-) sinus trouble, (-)
pain, (-)obstruction,
(-) sense of smell, (-) sneezing
THROAT(ORMOUTH&PHARYNX)
(-) pain, (-) dry mouth, (-) hoarseness, (-) sore throat, (-) bleeding gums, (-)
dentures,
(-) sore tongue, (-) difficulty of swallowing
NECK
(-) lumps, (-) swollen glands, (-) pain, (-) stiffness
BREASTS
(-) Lumps, (-) pain, (-) discomfort , (-) nipple discharge, (-) bleeding
RESPIRATORY
(-) cough, (-) hemoptysis, (-) dyspnea, (-) pain, (-) wheezing, (-) sputum
CARDIOVASCULAR
(-) heart trouble, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitations, (-
) dyspnea, (-) orthopnea,
(-) paroxysmal nocturnal dyspnea, (-) edema
GASTROINTESTINAL
(-) trouble swallowing, (-) heartburn, (-) ↓ appetite, (-) nausea, (-) vomiting , (-)
bowel movements
(-) color, (-) size of stools, (-) change in bowel habits, (-) rectal bleeding, (-) melena,
(-)hemorrhoids,
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(-) constipation, (-) diarrhea, (-) abdominal pain, (-) food intolerance, (-) excessive
belching or passing of gas.
URINARY frequency of urination: (-) polyuria, (-) nocturia, (-) urgency, (-) dysuria,
(-) hematuria, (-) incontinence, (-)stones
MUSCULO-SKELETAL
(-) muscle or joint pains, (-) back pain, (-) cramps, (-) stiffness, (-) sweating, (-)
tenderness, (-) limitation of motion,
(-) trauma, (-) weakness, (-) atrophy
NEUROLOGIC
(-) syncope, (-) blackouts, (-) seizures, (-) paralysis, (-) numbness, (-) tingling or
“pins or needles”,
(-) tremors and other involuntary movements, (-) pain, (-) sensory, (-) memory
HEMATOLOGIC
(-) anemia, (-) easy bruising, (-) bleeding
ENDOCRINE
(-) cold intolerance, (-) excessive sweating, (-) polydypsia, (-) polyuria
PSYCHIATRIC
(-) nervousness, (-) tension, (-) mood, (-) depression, (-) memory change, (-)
suicide attempts

PHYSICAL EXAMINATION

VITAL SIGNS:
BP: NA
PR: 128Bpm
Temp: 36.50C
O2 Stat: 98%
RR:26

Anthropometry measurements :
Head circumference – 37 cm
Mid Arm -11cm

babinski sign – negative

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LABORATORY DIAGNOSIS

CBC
Blood Electrolyte
Blood Glucose Level
Lumber Tapping For CSF Analysis
CT-Scan Of Head

DIFFERENTIAL DIAGNOSIS
Infectious – CNS= most likely
Metabolic – Electrolyte Imbalance
 Hypoglycemic

Tumor – less likely

Plan of management
 Phenytoin
 Diazepam
 If fever – paracetamol
 Iv fluid – D5 NSS
 Antibiotics