APIADO, TWINKLE ANN G.

MD 16th BATCH

Identifying Data
Date of Interview: February 8, 2017 @ 11:00pm
Informant: Patients Mother
Percent of Reliability: 90%
Source of Referral: Naval Biliran Provincial Hospital

General Data
RL.C is a 8 months and 12 days old female, infant, who was born last May 21, 2016, Filipino, Roman Catholic in affiliation
and recently residing at Brgy. Anas, Antipolo, Naval, Biliran. She was admitted for the 1st time at this center last February 8 at
around 8 oclock pm.
Chief complaint: Hematoma

History of Present Illness

The patient was apparently well until 2 weeks PTA, the mother noticed single, non-palpable, bluish violet hematoma on
her childs L side of the abdomen measuring about a peso coin. This was not associated with tenderness upon palpation. There
was no fever, no gingival bleeding, nor signs of GI bleeding. Thought it was just caused by being clumsy of the child the mother
disregarded the sign. There was no consultation done. There was no medication taken. There was no change in activity nor
appetite. The hematoma resolved spontaneously.
3 days PTA, hematoma recurred spontaneously on her lower extremities with the largest measuring 1 peso coin. Still
there was no fever noted. No other signs of bleeding noted such as gingival bleeding, epistaxis, or passage of black tarry stool.
This prompted the mother to bring the chid at Biliran Provincial Hospital and was managed as out patient. CBC was requested
which showed decreased platelet count. UA was also requested which revealed unremarkable. There was no medication given at
that time. They were then advised for admission and referral to a higher center for further evaluation and management of the
hematoma but temporary refused at that time due to financial constraint.
Day PTA, patient was then brought at this center hence this admission.

Personal History: Prenatal

The mother is a 33 y.o., G2P3 (1001) when she conceived the patient. She had her monthly prenatal check-up at
Barangay Health Station, performed by the nurse on duty. She received a total of 4 tetanus toxoid vaccine. She was also given
Ferrous sulphate which was taken on poor compliance due to its metallic taste. Routine laboratory was requested such as CBC,
Pelvic UTZ and UA. She claimed she was diagnosed with UTI at her 2nd month AOG and was prescribed with unrecalled antibiotic
which she took with good compliance. Follow-up check-up was not done but claimed to be well after 7 days of medication.
She denies exposure to radiation. There were no undue labor pains, vaginal bleeding and early rupture of bag of water.
The mother is a non-smoker and a non-alcoholic beverage drinker

Personal History: Birth

The patient was delivered full term, cephalic , via normal spontaneous delivery after 24 hours of active labor. It was
assisted by the physician on duty at Biliran Provincial Hospital. She claimed she had prolonged labor and was induced during the
delivery of the patient. A vigorous cry with an active movements was observed upon delivery. The umbilical cord was cut using
sterile scissors. The patient weighed

Personal History: Neonatal

The patient was able to breastfeed 1 hour after delivery and per demand thereafter. She was able to pass her 1st stool
and 1 urine within 24hours of life. Umbilical cord was cleaned using cotton balls soaked in clean water. There were no
st

complications observed such as foul smell, erythema and bleeding. It sloughed off after 7 days.
There were no jaundice, dyspnea, fever nor convulsions noted. There were also no congenital abnormalities observed.
Personal History: Feeding
The patient was exclusively breastfeed since birth up to her 6 months per demand of approximately 10-12x/day with 1-2
hours interval per feeding. At 8 months, formula milk (Bonamil formula milk for 0-6 months old) was introduced, 2 scoops of powder
milk into 4 ounce of water given 3x in a day and 1x in the night with the interval of 4-5 hours in 8hours span of time, consumed and
well tolerated.
Personal History: Growth & Development
Age Gross Motor Fine Motor Language Personal Social
1 month Raise head slightly when Throaty sounds Regards face
prone
2-3 Reaches for familiar Laughs
months objects
4-5 Rolls front and back Grasp objects
months
6-7 Sits with support Babbles
months
8-9 Crawls Imitate sound Feeds self with bottle
months

Personal History: Immunization

Vaccine Time Given Adverse Reaction(s)

BCG At birth None
Hepa B1 At birth None
DPT 1 3 months Fever (relieved with Paracetamol)
Swelling at injection site (relieved with hot
compress)
DPT 2 4 months Fever (relieved with Paracetamol)
Swelling at injection site (relieved with hot
compress)
DPT 3 5 months Fever (relieved with Paracetamol)
Swelling at injection site (relieved with hot
compress)
OPV 1 3 months None
OPV 2 4 months None
OPV 3 5 months None

Past Illness Medical Illness

The patient had no history of measles, chicken pox, mumps and other infections such as cough and colds. This was her
1st admission.

Family History
The father of the chid is a 43y.o. Apparently well.
Her mother is 33 y.o. apparently well.
There was no known heredofamilial diseases such as HPN, DM, thyroid and kidney diseases.

Psychosocial History
The patient was born May 21, 2016 and was raised in Biliran. The patient lives with her parents, and her 4 siblings. They
live in a 1 room house, made of light materials. They use communal water sealed toilet located 5 meters away from their house.
They have access to electricity. Their drinking water is from NAWASA which was not boiled. The left-over food are stored in a
covered container, and reheat prior to consumption. The family irregularly practice hand washing before and after eating, either
after use of comfort room.
 The patient has only 2 bottles for feeding. It is clean by washing of soap then immersing to boiled water for 5 minutes. The
water use for diluting formula milk is a purified drinking water.
They use charcoal for cooking. Garbage are dispose in a big trash can, and are collected once a week. They dont own
any domestic animals.
Her father is an elementary graduate and work as a pedicab driver. He earns 250/day. He is not a smoker nor an
alcoholic drinker. The mother is elementary level and a housewife. She takes care of her children. She is a non-smoker an
occasional local distillate drinker

Risk Factors
Vulnerable age group
Mixed feeding
Using only 2 bottle for feeding
Irregular handwashing practices

Physical Examination
The patient was examined on the ___ hospitalization hour. She is awake, afebrile, not in cardiorespiratory distress. The
V/S and anthropometric measures are as follows:

Vital signs Actual Normal Range

Temperature 36.5-37.5 C
Respiratory rate
Heart rate
BP not taken due to unavailability of
appropriate cuff.

Anthropometric Actual Ideal for Age Percentile Rank Z Score

Weight 8.5 kg
Recumbent Length 66 cm 70 cm 0
Head Circumference 41 cm 41 cm 0
Chest Circumference 40 cm 41 cm 0
Abdominal 40 cm 41 cm 0
Circumference
MUAC 14 cm

Integuments
Inspection: Fair skin with brown complexion, acyanotic, no jaundice. Pinkish nail beds, short trimmed nails, no clubbing, capillary
refill test is <2 seconds. With hematoma scattered on lower extremities.
Palpation: Warm, soft with good skin turgor. No lumps, no masses
HEENT: Head
Inspection: Symmetric with fine evenly distributed hair.
Palpation: Anterior fontanel is open, diamond shape, at 1cmx1cm, soft, no hematoma nor lesions. Sutures are not gaping and are
not overlapping. Posterior fontanel is close.
HEENT: Eyes
Inspection: Symmetrical eyes with evenly distributed eyebrows and eyelashes. Anicteric sclera with pinkish palpebral conjunctiva.
No corneal opacity nor hemorrhages. No periorbital/lid edema nor discharges.
HEENT: Ears
Inspection: Symmetrical, superior border of pinnae aligned with the eyes. No lesions and discharges noted.
Palpation: No masses, no swelling in postauricular/mastoid region.
HEENT: Nose
Inspection: Patent nares, no alar flaring, no nasal discharges.Nasal septum at midline. Nose bridge not deviated. Pinkish nasal
mucosa, no lesions.
HEENT: Mouth & Throat
Inspection: Moist mucous membrane, pinkish in color. No cleft lip, no cleft palate, no tongue tie. No lesions.
HEENT:Neck
Inspection: Symmetrical,no lesions. Neck vein not engorged.
Palpation: Neck is supple. No palpable cervical lymph node. No masses noted.
Chest & Lungs:
Inspection: Symmetrical chest expansion, no retractions, no visible deformities.
Palpation: No masses, no swelling, non tender.
Percussion: Not done.
Auscultation: Bronchovesicular breath sound
Cardiovascular:
Inspection: Adynamic precordium. Non visible pulsations.
Palpation: PMI at 4th left ICS MCL. No heaves nor thrills.
Auscultation: Normal HR _______ bpm with regular rhythm, synchronous with PR. No murmur, no bruits.
Abdomen:
Inspection: Protuberant, symmetrical, no visible pulsation,no dilated veins. Umbilicus without lesions and discharges.
Auscultation: Normoactive bowel sounds @ 20 per minute.
Percussion: Not done
Palpation: Skin fold test is negative. Soft, non-tender, no masses. Liver spleen & kidneys are not palpable.
Genitourinary tract:
Inspection: Grossly female, no discharges
Inguinal region:
Palpation: Non tender, femoral lymph nodes not palpable.
Extremities:
Inspection: Unimpaired mobility, no deformities, no atrophy, with full pulses.
Spine:
Inspection: Spine straight, no abnormal tuft of hair, no dimpling or birthmark noted.
Palpation: No masses, non tender.

Neurologic Examination
Mental Status: The patient was asleep, cries when disturbed and changed in position.
Cerebellar: No nystagmus
Cranial Nerves:
CN I not tested
CN II and III pupils equally round and briskly reactive to light, both direct and consensual.
CN III, IV, VI dolls eye
CN V not tested
CN VII no asymmetry of face when crying
CN VIII blinks when sudden loud noise (1 clap) is made
CN IX and X gag reflex not tested
CN XI not tested
CN XII not tested
Motor Function
The patient has active flexion and extension of both upper and lower extremities without limitation.
Sensory
Patient is able to withdraw both of her feet when flickered.

Pathologic Reflexes
Ankle clonus negative. Is elicited by quick, vigorous dorsiflexion of the foot while the knee is held in a flexed position. Positive
result when the foot causes a series of involuntary flapping, rhythmic muscular contractions.
Meningials Sign
Bruzinzkis sign- Not done. It is negative sign when the neck is flexed during severe neck stiffness, the hip and knees usually flexed.
Kernigs sign- negative sign; the patient thigh was flexed at the hip and knee at 90 degree angles then subsequently extending the
knee. Result is usually painful.
Autonomics
No excessive sweating