Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 237 views

    Pediatric Case Presentation 1

    Uploaded by

    Laica Barcelona
    This case involves an 8-month-old male infant who presented with diarrhea. According to the history, the patient had watery, green-colored stool for 2 days after being fed monggo soup. On physical exam, the patient's vital signs and growth parameters were normal. The physical exam was otherwise unremarkable except for noting intercostal retractions. The patient's past medical and family histories were non-contributory.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Pediatric Case Presentation 1

    Uploaded by

    Laica Barcelona
    237 views18 pages
    This case involves an 8-month-old male infant who presented with diarrhea. According to the history, the patient had watery, green-colored stool for 2 days after being fed monggo soup. On physical exam, the patient's vital signs and growth parameters were normal. The physical exam was otherwise unremarkable except for noting intercostal retractions. The patient's past medical and family histories were non-contributory.

    Original Description:

    Original Title

    PEDIATRIC-CASE-PRESENTATION-1

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This case involves an 8-month-old male infant who presented with diarrhea. According to the history, the patient had watery, green-colored stool for 2 days after being fed monggo soup. On physical exam, the patient's vital signs and growth parameters were normal. The physical exam was otherwise unremarkable except for noting intercostal retractions. The patient's past medical and family histories were non-contributory.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    237 views18 pages

    Pediatric Case Presentation 1

    Uploaded by

    Laica Barcelona
    This case involves an 8-month-old male infant who presented with diarrhea. According to the history, the patient had watery, green-colored stool for 2 days after being fed monggo soup. On physical exam, the patient's vital signs and growth parameters were normal. The physical exam was otherwise unremarkable except for noting intercostal retractions. The patient's past medical and family histories were non-contributory.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 18

    PEDIATRIC

    CASE PRESENTATION

    REFUERZO, MAUI
    PUNAY, EARL JOSEPH
    S.
    HISTORY

     Date and Time: March 23, 2020 at 10:30 am


     General data:
     This is the case of Y.J, a 8 months old, male, Roman Catholic, Filipino, from Vigan
    City Ilocos sur, born on May 14, 2019 was admitted to Gabriella Silang Medical
    Hospital on Jan. 22, 2020.
     Informant: mother and grandmother of the patient
     General complaint: Diarrhea
    HISTORY OF PRESENT ILLNESS

     2 days prior to admission, patient had LBM of around 5 times with


    watery consistency, green-colored, Without other signs and
    symptoms after being fed with monggo soup by the mother. No
    medications were taken. There were no other interventions. 1 day
    prior to admission, the patient still has lbm prompting the mother to
    bring the baby to gabriella hospital for consultation. Hence, patient
    was admitted.
    PAST PERSONAL HISTORY
    PRENATAL
    Patient was born in a 29 year-old mother, a G3P3 (3-0-0-3). Patient
    was delivered via Normal Spontaneous Delivery. Mother had her
    regular prenatal check up and had no any maternal illness at that
    time. No other medications were taken except for her vitamins.

    BIRTH
    Patient was delivered term and weighed 2.9 kg. No history of
    complications at birth.
    FEEDING HISTORY
    Patient is given breastmilk and formula milk 12 times a day. The
    patient also eats Potatoes, Squash, and Cerelac. Mother gives him
    Absolute water to drink.
    PAST MEDICAL HISTORY

    CHILDHOOD ILLNESS
    He had varicella when he was 1 year old.
    MEDICAL HISTORY
    No known allergies.
    SURGICAL HISTORY/ACCIDENTS
    No history of any surgery or accident.
    DRUG REACTION HISTORY
    No history of any drug reaction.
    PSYCHIATRIC HISTORY
    No psychiatric evaluation done.
    IMMUNIZATION HISTORY

     The patient was given DTaP, HBV, and polio vaccines. The patient
    was not yet given MMR vaccine (1 year old)
    FAMILY HISTORY

     Family members are said to be healthy


    SOCIOECONOMIC HISTORY

     The patient lives with his father, who is a free-lance, and his
    mother who is a housewife. They live in a concrete house with 2
    bedrooms and a comfort room.
    ENVIRONMENTAL HISTORY

     The source of water for both the household use and drinking is from a so
    called “poso” or hand water pumps. The patient drinks Absolute Water.
     They practice proper segregation of their garbage.
    PHYSICAL EXAM
     General survey
     patient is asleep, cries briefly then stops. Wakes up quickly when
    stimulated. Strong with normal tone.
     Vital Signs
     Heart rate: 90 beats/min
     Respiratory rate: 28 cycles/min
     SpO2: 98%
     Temperature: 37.9 °C (Axillary)
     Anthropometrics
     Length: 77cm
     Weight: 10.5kg
     Head circumference: 49.5 cm
     Mid arm circumference- 17 cm
     Z scores??
    PHYSICAL EXAM

     SKIN. Skin: Pinkish, warm to touch, Good skin turgor, no pallor, no cyanosis, no
    jaundice, no rashes.
     Head: Normocephalic; no lesions. Hair of average texture. Scalp without lesions.
    Non-bulging, non-depressed anterior fontanel
     Face: Face is symmetrical. No unusual facies or deformities noted.
     Eyes: Symmetric with normal extraocular movements. Pupils symmetrically
    reactive to light.
     Ears: Located at the level of the eyes. Normal pinna; no external abnormalities.
     Nose: Normal nares; septum midline. No alar flaring. No nasal discharge. Sinus non-
    tender.
     Mouth & Throat : Lips is pink with no fissures. Buccal mucosa is moist, smooth,
    shiny and pink. Tongue is symmetrical. Frenulum is in the midline Pink,
    nonbleeding gums. Palate is intact.
     Tonsils: Tonsils are pink with no exudates
    PHYSICAL EXAM
     NECK
     Supple, midline trachea, no thyroid palpable. No masses palpated. No rigidity.
      
     CHEST AND LUNGS
     Intercostal retractions noted. Good chest expansion. No tachypnea or dyspnea. No congestion. No
    rhonchi, rales, or wheezes. Clear to auscultation. Breath sounds are normal
     
     CARDIOVASCULAR
     PMI in 4th left intercostal midclavicular line. Normal S1 and S2. No murmurs or abnormal heart
    sounds. Normal femoral pulses; dorsalis pedis pulses palpable bilaterally.
     
     BREASTS
     Normal, and no mass palpated.
     
     ABDOMEN
     Flabby, non-tender, non-distended abdomen with Increase and high pitched bowel sounds.
    Symmetrical without distention. No masses or tenderness.
    PHYSICAL EXAM

     EXTREMETIES
     No cyanosis, clubbing, or edema noted.

     MUSCULOSKELETAL
     No joint deformities. Good range of motion.
    NEUROLOGIC EXAM

     Reacts to sound

     Di ko na alam haha

    You might also like