SARROZA, XHIAN

7/31/2019 SARROZA, XHIAN

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1) MEDICAL HISTORYPatients Name: Xhian Sarroza

Informant: Mother

Reliability: Good

General Data

Birthday: 08/10/2010 Age: 1 year and 9 months 5 days Address: zone I Dasmarinas, Cavite Born in: Salitran Lying IN clinic Born again 1st time admitted last Tuesday (05/22)

@ 4pm

CC: Seizure

HPI:

1 day PTA had a fever episode (39C) of sudden onset, mother gave tepid sponge bath, and paracetamol drops1.25 ml every 4 hours, fever subsided.

Within the day - Fever episodes were intermittent, no loss of appetite but patient would vomit everything heeats nanghihina 4 hours prior to admission, fever remained @ 39C with a seizure episode of short duration (nangisay pero very

saglit lang), mother continued sponge bath with ice, and gave paracetamol with the same dosage,

Few mins PTA, fever peaked @ (40C) with another seizure episode (duration was not recalled, caregivers werealready panicking) was noted. grand mother noticed the ff:

o Upper and lower extremities were stiffened and extended (isipin nag seizure nga eh!)o Back was arched upwardo Backward rolling of the eyeso Tuloy tuloy na nangingisay, kaht na hawakan mo na..

Which prompted immediate hospitalizationPMH

Maternal/birth hx 26 y/o mother, G1P1 (1001), delivered via normal spontaneous vaginal delivery w/ocomplications during labor and delivery; px was not in any physical distress and was immediately discharged

Prenatal regular checkup @ bgry HC; took multivitamins and ferrous sulfate as advised; diet consisted ofmeat, fried food, and preserved goods (eg. Hotdog); no changes in appetite or weight were noticed; no vices

such as alcohol and smoking

Natal 1st child; birth wt approx 3000lbs Hospitalization/childhood illnesses

o no other major hospitalizationso Had bronchitis last Jan 2012 (4 mos ago)o Had 2 episodes of tonsillitis (1st November 2011; 2nd April 2012)

No allergies Feeding hx

o Since birth, px was breastfed for 2 wks then shifted to bottlefeeding (Bona S1)o Bona S1 for 6 months; consumed 4 bottles (3oz/bottle) within the dayo Feedingincreased eventually (#bottles consumed were not noted)o From Bona s1, px was shifted to Anchor for 3 mos Nido (3mos) Bear brand (present); consumes

at least 5 bottles (222ml)/day

Growth and Devt (milestones)o @ 6mostooth eruption began (central incisors)


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o @ 8mosable to sit upright; able to say two-syllable words (eg. Mama)o @ >12mos able to stand and walk in a walkero @ 21 mos able to run around (very makulit); able to combine two-syllable words in a meaningfu

sentence; usually picks up objects/food (eg. Biscuits) with pincer grasp; able to feed self with biscuits;

able to point at people when asked to identify (hal. Mom sinong kaaway mo? then baby points at

anna); pag binigyan mo ng object at ni-try mong ipahawak sa kamay na may hawak pa, ittry niyang

kunin yung inaabot mong object with the vacant hand; follows one-step command without gestures;

pacified when given an object to play with; able to distinguish primary caregivers (mother, lola, tita

from strangers; prefers to be carried by mother most of the time; tooth eruption (2 molars, mandiblepart); currently has 8 teeth (4 sa taas, 4 sa baba)

Immunizations complete (yung included sa EPI program ng DOH kasi sa HC sila nagpapabakuna)Family HX

(+) asthma and hypertension, maternal side Convulsion episodes were also noted among the pamangkins (age not specified), paternal side

ROS (Pertinent)

Skin small wound scars over dorsum of left hand; erythematous macules (insect bites) over dorsal aspect ofleft foot

Respiratory currently has cough with whitish phlegm (duration not asked) GIT/GUT bowel movement: 1x/day usually in the morning with firm consistency and yellowish in color

frequent urination within the day, no difficulty; no toilet training yet!

Nutrition multivitamins were given for 2 mos since birth then stopped resumed multivitamin intake @12 mos, which only lasted for a month, then stopped (kasi niluluwa ng baby)

Other organ systems are unremarkable

2) PHYSICAL EXAMINATION General appearance: px appeared to be active during examination; played a lot with the tita and mom; would

cling on to mother when approached by examiner; with good eye contact; with endomorphic built; with IV line

splinted at R hand

VS:o Temp: 36Co HR: 122 bpm, regular, (-) murmurs/bruito RR: 56 cpm

Anthropometric measures:o HC: 44cmo Chest circ: 45cmo Abdomen: 51cmo Height: 95cmo Weight: 10.5kg

Skin: fair-skinned; smooth, with good turgor, lesions check ROS; (-) masses, discolorations; (-) clubbingcyanosis of nails; good capillary refill; Hair black, evenly distributed, no parasitic infestation

Head: fontanelles were not assessed (baby was irritated); normocephalic; (-) masses, lesions; symmetric faciafeatures

Eyes: symmetrical; (-) external lesions; follows moving objects; other parts not assessed kasi px was crying Ears: normoset ears; (-) lesions in the pinna; follows direction where sound/name is heard; other parts not

assessed kasi px was crying

Nose: no external lesions noted; nares symmetrical; (-) alar flaring noted; other parts not assessed kasi px wascrying


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Neck: (-) stiffening, full range of movement, (-) palpable cervical/submandibular/submental/periauricular lymphnodes; trachea is in the midline; thyroid gland not assessed (baby was irritated)

Chest and Lungso Symmetrical chest expansion; (-) external masses/lesions; (-) thoracic deformitieso (-) intercostal retractionso Abdominal breathero Bronchovesicular sounds heard mostly over the bilateral upper lung fields; (+) rales? (basta malakas but

not bronchovesicular, would indicate na may phlegm over that lung field) best heard over right lower

lung fieldo Percuss/palpate not done

Cardiovascularo S1=S2 auscultated directly below areola of the nipple (paki-research na lang kung anong ICS to)o No other abnormal heart sounds were heard upon auscultationo Inspection (what to document for pedia px paki-research na lang)

Abdomeno Slightly distended (just imagine yung usual tiyan ng baby), soft in consistency, fair-skinned, (-) scars

masses, lesions; umbilicus is inverted

o Normoactive bowel sounds all over abdomen; 4/min, best heard over R iliac region/RLQ Musculoskeletal

o(-) deformities

o With good tone and strength (5/5) able to raise extremities against gravity and against resistance Neurologic

o Cranial nerves: Full EOMs intact III, IV, VI Follows moving objects and responds accordingly intact II With full facial expression (smiles, cries, stares) intact VII Sticks out tongue intact XII Raises shoulders/ full upper extremity ROM intact XI No difficulty with swallowing intact IX, X

o Reflexes: No pathologic reflexes observed Paki-check na lang yung dapat na wala sa kanya, kasi reflexwise ok naman siya.

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SARROZA, XHIAN