PEDIATRIC INTEGRATION

PRECEPTOR:
Dr. Andy T. Panes

PEDIATRIC RESIDENT:
Dr. Fairr Carlien Jacildo

PRESENTED BY:
Alejandro, Nicole
Alibuyog, Regine Samantha
Alvarez, Ma. Lothel
Amihan, Alyssa
Antolo, Pauline Mae
Araneta, Shalimar
Ardiente, Joy Ann
Arias, Lynda Bianca
Ariola, Dennyl Eve
Aristosa, Ariane
Asparo, Daniela Rona
Bayatan, Johanna Erica
Borres, Monique
Bustillo, Melissa
Cabalfin, Faith

GROUP A MD-3
September 15, 2022
 PEDIATRIC CLINICAL HISTORY

GENERAL DATA:
Patient C-Jay Apawan, a 17-day-old, male Filipino, Roman Catholic, was
born in Cadiz City on August 24,2022. History was taken on August 26, 2022 at around
10:00 a.m. The source of history is the patient’s mother, 28 years old, a housewife, and is
the main caretaker of the patient. The reliability of the source is 95%.

CHIEF COMPLAINT:
Poor suck

HISTORY OF PRESENT ILLNESS:

2 days PTA, onset of poor suck, yellowish skin discoloration and abnormal
twitching movements of the mentum and both upper and lower extremities exhibiting
pedaling movements lasting for less than 2 minutes occurring 4x/day apneic spells,
cyanosis. Patient was brought to St. Anne Hospital in Cadiz. Baby was given unrecalled
antibiotics for 2 days.
1 day PTA, patient's condition had no improvement and was referred to
CLMMRH for further management.

BIRTH AND MATERNAL HISTORY:

I. Gestational History:
C-jay was born to a 28-year-old G4P4 (4003) mother who had prenatal
checkups which only started at the 2nd trimester until term at their local health
center done by a midwife. She had no illness throughout the pregnancy except for
a 2-week cough that occurred during the 7th month. No prior consultation was
done, no medications were taken to alleviate the cough. Mother also denied
smoking, alcohol consumption, and use of illicit drugs. Tetanus vaccine was given
to the mother during the 7th month and immediately after birth. Intrapartum
medications given were only Folic acid. Mother was not tested for any laboratory
studies but sonographic imaging was done and was unremarkable. LMP of mother
is November 11, 2021 and expected date of delivery is August 18, 2022

II. Birth History:

C-Jay was delivered full term via NVSD in cephalic presentation at Cadiz City
Lying-In Center by a midwife. Patient was put in the mother’s chest after birth
and was breastfed immediately. APGAR Score for the first minute is 9.
III. Neonatal History:
C-Jay was born with a Birth weight of 2.8 kg, birth length of 49 cm, and a
head circumference of 31 cm. There were no complications during delivery and
was discharged hours after birth.

REVIEW OF SYSTEMS (For Newborn patients to 18 Years of Age)

GENERAL:
Weight loss EARS:
Weight gain Hearing changes
Fatigue Tinnitus
Fever Vertigo
Chills Ear aches
weakness Infection
fussiness Discharge
Trouble sleeping Use of hearing aids
Appetite change/poor feeding
Sleeping more than usual NOSE AND SINUSES:
Sleep disturbance Frequent colds
Nasal stuffiness
HEAD: Itching
Headache Nose bleeds
Head injury Runny nose
Lightheadedness
MOUTH AND PHARYNX:
EYES: Condition of teeth
Eye drainage Condition of gums
Vision changes Toothache
Eye grade: Bleeding gums
OU: Use of dentures
OD: Filling noted
OS: With braces or retainers
Use of eyeglasses Sore tongue
Use of contact lenses Dry mouth
Eye Pain Frequent sore throats
Itchy Eyes Hoarseness
Eye Redness/ Swelling Halitosis
Light Sensitivity Thrush
Excessive tearing Non-healing sores
Double vision
Blurry vision NECK:
Spots Swollen glands
Specks Goiter
Flashing lights Lumps
Glaucoma Pain
Cataracts Stiffness
MOUTH AND PHARYNX: Need to use pillows at night to
Condition of teeth ease breathing
Condition of gums Need to sit up at night to ease
Toothache Dyspnea with activity
Bleeding gums Dyspnea at rest
Use of dentures Edema
Filling noted
With braces or retainers BREASTS:
Sore tongue Lumps/Mass
Dry mouth Pain
Frequent sore throats Discomfort
Hoarseness Nipple discharge
Halitosis Nipple changes
Thrush Breastfeeding
Non-healing sores
GASTROINTESTINAL TRACT
NECK: Trouble swallowing
Swollen glands Pain in swallowing
Goiter heartburn
Lumps Food intolerance
Pain Early satiety
Stiffness Nausea/vomiting
Bowel movement
RESPIRATORY: Change in bowel habits
Cough Pain with defecation
Sputum/Phlegm production Rectal bleeding
Sore throat Black or tarry stool
Dyspnea Hemorrhoids
Orthopnea Constipation
Bradypnea Diarrhea
Tachypnea Abdominal pain
Wheezing Excessing belching or passing
Noisy Breathing of gas
Pleuritic pain Jaundice
Liver trouble
CARDIOVASCULAR: Gallbladder trouble
Heart problems Hepatitis
High blood pressure
Low blood pressure URINARY:
Fast/irregular heartbeat Painful urination
Rheumatic fever Polyuria
Heart murmur Oliguria
Chest pain Anuria
Chest discomfort Nocturia
Palpitation Dysuria
Fainting Hematuria
 Pyuria
Proteinuria MUSCULOSKELETAL:
Glucosuria Muscle pain
Lipiduria Joint pain
Foul smelling urine Stiffness
Flank pain Arthritis
Kidney stones Neck pain
Ureteral colic Backache
Suprapubic pain Tenderness
Bladder fullness Weakness
Incontinence Limited ROM
Dribbling Dislocation
Bed wetting Swelling
Refusing to use extremities
GENITAL: General
Change in sexual habit SKIN:
Sexual dysfunction Dryness
Past STD Warm to touch
Cold to touch
GENITAL: Male Rashes
Hernia Pruritus
Penile discharge Lumps
Penile sore Sores
Testicular pain Scars
Testicular lumps Bruising
Scrotal pain Wounds
Scrotal swelling Changes in hair or nails
Changes in size or color of
GENITAL: Female moles
Dysmenorrhea Hypothermic
Menopause Jaundice
Vaginal discharge
Vaginal sore NEUROLOGIC:
Vaginal itching Vertigo
Changes in mood
PERIPHERAL VASCULAR: Incoordination
Intermittent leg pain with Fainting
exertion Blackouts
Leg cramps Seizures
Varicose veins Weakness
Past clots in the veins Speech delay
Color change in fingertips or Recent head injury
toes during cold weather Paralysis
Swelling the extremities Numbness
Swelling with redness Tremors
Swelling with tenderness Tingling sensations
 Twitching movements Hematomas
Attention changes Bruises
Speech changes Pallor
Changes in orientation Past blood transfusions
Insight changes Transfusion reaction
Changes in judgment Cyanosis
Headache
Dizziness ENDOCRINE:
Thyroid trouble
PSYCHIATRIC: Heat tolerance
Nervousness Cold tolerance
Tension Excessive sweating
Mood Excessive thirst
Depression Excessive hunger
Memory changes Excessive urination
Suicidal ideations Edema
Anxiety Hay fever
Irritability
Attention Problems IMMUNE
Sleep Problems Allergic Reaction
Eczema
HEMATOLOGIC: Hives
Anemia Seasonal Allergies

PAST MEDICAL HISTORY

The patient has no history of hospitalizations, previous surgeries, accidents, or
injuries. Moreover, the patient has no history of any allergies.

FAMILY HISTORY
Except for the patient’s maternal grandmother having hypertension, there are no
metabolic and hereditary diseases in the family. History of TB, Hepa A or B or any other
chronic types of infectious conditions does not exist in their family.
GENOGRAM
PERSONAL AND SOCIAL HISTORY
C-jay is the 4th child of Caren, 28 years old and Gerald, 37 years old. Patient’s
father works as a fisherman while his mother is a plain housewife. There are only 5
members in the house. Two of the children were in elementary school. His eldest brother
was born at 37 weeks of gestation via NSVD but died 5 days after birth. Mother recalled
the same symptoms was experienced by her first child prior to demise. Second child is
already 12 years old which she delivered 37 weeks via NSVD. Third child is now 8 years
old and was also delivered 37 weeks via NSVD.

NUTRITION AND FEEDING HISTORY

Baby was breastfed by her mother every 2-3 hours.
Due to poor sucking of the baby, the mother’s breast milk dried up, then she was advised
by her attending physician to take malunggay capsule and the milk eventually started to
flow.

DEVELOPMENTAL HISTORY
● Gross motor: Lies in an extended position, patient turns head side to side, Head
lags on ventral suspension, Doll's eye movement of eye when turning body
● Personal and Social: Fixates face on light in line of vision, visual preference of
mother’s face
● Reflexes: Tonic neck; grasp reflex; rooting and sucking reflex is present

ENVIRONMENTAL HISTORY
The family lives near the seashore and the houses surrounding were situated near
each other. Their source of water is via faucet from Cadiz District Water Supply. Garbage
is collected by the garbage collectors. Their comfort room is separated 1-2 meters away
from the house and their type of flushing is via bucket. They used mineral water for
consumption and cooking.

IMMUNIZATION HISTORY

Date Vaccination Place Dose

August 24, 2022 Hepatitis B 0.5ml Cadiz City Lying-In Single Dose
IM Center
 PHYSICAL EXAMINATION

GENERAL SURVEY:
The patient came in being carried by the mother. Upon inspection, she looked well-
developed. The patient was asleep and comfortable.

VITAL SIGNS:

Vital Sign Patient Result Normal Values Correlation

(0-3 months)
Blood Pressure Not taken 65-85/ 45-55 mmHg -----

Heart Rate 130 bpm 100-150 Normocardia

Respiratory Rate 28 bpm 35-55 bpm Bradypnea

Temperature 35.8c 36.6-37.9 C/ 97.9- Hypothermic
100.2F

O2 saturation 91 >95 Mild hypoxia

ANTHROPOMETRIC DATA

Expected measurement Physical Examination

(according to WHO)
Weight 2500 grams (2.5kg) 2,800 grams (2.8kg)
(Filipinos)
Length 50 cm (0.5m) 49 cm (0.49m)
Head Circumference 35cm (32-37 cm) 31 cm
Chest Circumference 30-33 cm 30 cm
Body Mass Index BMI =Wt in Kg -:- (Lt or Ht 11.66
in meter)2 Percentile: 15th percentile
according to WHO
Z score: -1SD according
to WHO
BODY MASS INDEX
Z SCORE INDICATORS

The given weight of 2.8 kg intersects with the given age of 0 weeks, yielding a
z-score of -1 SD. This is interpreted as a normal weight concerning his age.
 The given length 49 cm at 0 weeks yields a z-score of 0. This means that the
patient’s length is normal with his age.

The given weight of 2.8 kg when plotted against the given length of 49 cm at 0
weeks yields a z-score between -1 SD based on the WHO chart. This means that the
patient’s weight is normal concerning the patient’s length.
 The given head circumference of the patient is 31 cm at 0 weeks falls under the Z
score of -2SD based on the WHO chart indicating microcephaly.

HEENT
● Head (-) swelling, redness, foreign
(+) yellow discoloration bodies, drainage, deformities
(-) gross deformities (-) tenderness, masses
(+) symmetrical face, (-) deformity
Normocephalic ● Nose
Normal contour Symmetrical alar
Fontanelles not closed, (-) bulging Pinkish midline septum
(-) masses, depressions, elevations (-) bleeding, discharges,
congestion
● Eyes (-) tenderness
Anicteric sclerae Bony nose bridge and ala are
Pink conjunctivae cartilaginous in harness
Aligned eyes
(-) edema/lesions/swelling ● Mouth - examination not performed
due to COVID-19 health protocols
● Ears
Symmetrical in shape and size ● Neck
Ears are aligned with eyes (+) yellow skin discoloration
(-) lesions (-) depressions, masses, lesions
 (-) palpable mass, swelling
CHEST AND LUNGS
(-) bruises, masses, lesions, retractions
(+) alar flaring
(+) Symmetric, with good chest expansion
(+) lung resonance
(+) bronchovesicular breath sounds
(+) apnea
(-) adventitious sounds such as rales, wheezes or rhonchi

CARDIOVASCULAR
(-) visible bruises, masses
(+) normal cardiac rate and rhythm
(+) adynamic precordium
(+) PMI is noted near the midclavicular line at 4th intercostal space
(-) heaves and thrills
(-) murmurs

ABDOMEN
(-) concealed bruises, rashes, masses, abnormal pigmentation or discoloration
(-) dilated veins
(-) soft non-distended abdomen
(-) bruits and friction rubs
(+) tympanic in all four quadrants of the abdomen
(+) umbilicus at the midline
(+) foul smelling umbilicus

SKIN AND EXTREMITIES

(+) jaundice
(+) cyanosis
Slightly cold to touch
(-) hypopigmentation
(-) lesions, masses
(+) full pulses

GENITALIA, RECTUM & ANUS

Normal external genitalia
(-) skin lesions
Bilaterally descended testes
Intact rectal vault
 NEUROLOGICAL EXAMINATION
(Done during 13th day of admission in CLMMRH)

LEVEL OF ALERTNESS
(+) asleep and comfortable

CRANIAL NERVE EXAMINATION

II Optic (Visual acuity) The patient recognized the mother's face

and tracking of the face was observed.
II, III Optic, Ocular The patient displayed an optic blink reflex
(response to light) in response to the light.
III, IV, VI Oculomotor, No eye deviation was observed upon
Trochlear, primary gaze.
Abducens
V Trigeminal (motor) The sucking reflex was intact upon
breastfeeding.
VII Facial Upon crying, the patient showed facial
symmetry. Palpebral fissures, nasolabial
folds, and corners of the mouth were
symmetric.
VIII Vestibulocochlear Blinking of both eyes in response to loud
noise. Respond to mother’s voice.
V, VII, XII Trigeminal, Facial, Sucking was observed
Hypoglossal
IX, X Glossopharyngeal Coordinated swallowing upon
,Vagus breastfeeding
XI Spinal accessory Not done because this requires flexion
and rotation of the head.

XII Hypoglossal The tongue moves upon yawning. Upon

pinching the nostrils, the patient opened
his mouth with the tip of the tongue to the
midline.
BALLARD SCORE
MOTOR DEVELOPMENT

Motor Strength spontaneous movements as well as Good muscle strength.

movements
against resistance exerted by the
mother. There is symmetry of
movements

DEVELOPMENTAL REFLEXES (PRIMITIVE REFLEXES)

Reflex Response Appearance
Rooting and Search to suck stimulus through the Present
Sucking Reflex breast of the mother, sucks breast
strongly
Grasp (Palmar Hand and toes grasp to stimulus Present
and Plantar)
Moro/Startle Extension followed by flexion of the Present
Reflex upper limbs
Tonic Neck Fencing posture of extension of Present
limbs towards direction of head