case protocol part 1

7/27/2019 Case Protocol Part 1

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CASE PRESENTATION:

This is a case of K.C., a 4 y/o male from Imus, Cavite who came in for the first time at ourinstitution due to abdominal pain.

I. HISTORY OF PRESENT ILLNESS

3 days PTC- +vague abdominal pain accompanied with intermittent fever (38-39 C); self

medicated with paracetamol (10mkd) affording temporary relief, no consult done

Night PTC - +vomiting, non-projectile, non-bilous, 3x

Day Of Consultpersistence of fever and abdominal pain

II. PAST MEDICAL HISTORY

A. PRENATAL AND BIRTH HISTORY

Born fullterm to a 27 y/o G3P3(3003) via Low Segment Ceasarian Section III (I x CPD) at

Alaminos Western Hospital BW-3.6kgs with no fetomaternal complications

B. FEEDING HISTORY

Exclusive breastfeeding up to 3 months; formula feeding with NAN 1 up to 6 months; NAN 2

from 6 months up to 1 y/o, Promil from 1 to 2 y/o, Enfakid from 3 y/o up to present; weaned at 6

months old

III. DEVELOPMENTAL HISTORY

Smiles2 mos First word DADA 6 mosHolds Head4 mos First Tooth Eruption7 mos

Reach Objects - 5 mos Rides a Tricycle2y/o

Rolls Over6 mos Toilet Training2y/oTransfers Objects7 mos Rides a Bicycle3 y/o

Sits Alone9 mos Dress Ones Self 4y/o

Stand Alone11 mos

Walks Alone1 y/o

IV. IMMUNIZATION HISTORY

BCG, DPT3, OPV3, HepB3, Measles(-)Hib, (-)Chickenpox, (-)MMR, (-)Flu, (-)Typhoid, (-)HepA, (-)Meningococcal

(-)Pneumococcal


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V. HISTORY OF PAST ILLNESSES

(+) Measles

8 mos(+) Roseola1 y/o(+)chickenpox1 y/o and 2 mos

Treated for Primary Complex x 6 mos1 y/o and 3 mos

(+) BFC at 2 y/o and was admitted at Alaminos Western Hospital(-)Hx of operations

VI. REVIEW OF SYSTEMS

HEAD: no headache, no head injury

EYES: no visual changes, no eye discharge, no eye redness, no eye injuries

EARS: no difficulty with hearing, no ear discharge, no ear infectionsNOSE: no discharge, no epistaxis

MOUTH AND THROAT: no sore throat, no difficulty in swallowing, no dental defects

NECK: (-)CLAD

LUNGS: no cough, no shortness of breath, no chest pain, no wheezingHEART: no murmur, no cyanosis, no pain over heart, no edema

GASTROINTESTINAL: +loss of apetite, no diarrhea, no constipation, no abdominal

distention, no jaundiceGENITOURINARY: no hematuria, no dysuria, +frequency

EXTREMITIES: no weakness, no deformities, no difficulty in walking or moving extremities,

no joint pains and swelling, no muscle pain/cramps

NEUROLOGIC: no headache, no dizziness, no seizures, no numbnessSKIN: no rashes, no bruises, no bleeding, no pallor

VII. FAMILY HISTORY

(+)DMpaternal grandmother and maternal grandfather

(+) Asthmamaternal aunt and paternal uncle(+) HPNpaternal grandfather and maternal grandfather

(+) Heart Diseasepaternal grandfather

(+) Thyroid Diseasematernal aunt

(-) Cancer (-) Seizure (-)Blood disorders

VII. SOCIAL HISTORY

The patient is a kindergarten student at Academia D. San Rafael Casa Bambini at Imus Cavite. ANuclear Family living in a townhouse with 42 sq m floor area. The Father is a BS Marine

Transportation graduate at the Lyceum of the Philippines University (LPU) and works as an Able

Seaman since 2000 and is the breadwinner. The mother is a BS Tourism graduate at LPU and isthe main caretaker. The family has an income of P25,000-30,000 monthly.


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VIII. PHYSICAL EXAMINATION

GENERAL: awake, not irritable, not in distress

BP:90/60 CR:92bpm RR:20cpm T:38.2

SKIN: good skin turgor, CRT

case protocol part 1

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