Michael B.

Valderrama
31, 2015
MD-120075
Neonatology: Well Baby Write Up
Pediatrics

July
Dr. Malayan
Ospital ng Makati

Identifying Information
Roxas Baby Girlnth-old male, born on Jan 11, 2015, Roman Catholic, Filipino, single,
from Silangang Mayo, Lucena city who was admitted for the first time at the Philippine
Childrens Medical Center on June 8, 2015.
Informant Reliability
He was accompanied by his mother who served as the informant with 90% reliability.
Chief Complaint
Bloody Stools
History of the Present Illness
Four days prior to admission, the patient was noted to be irritable with passage of
yellowish watery stools, 1 diaper full with no mucus, followed by blood streaked stools
amounting to 1 tsp and blood clots amounting to 2 tbsps with the consistency of strawberry
jam with no accompanying fever. The patient was brought to the nearest hospital where a
stool exam was performed which showed (+) for E. histolytica with trophozoites. They were
advised admission to PCMC.
On the day of admission, still with persistence of fresh blood in stools, low pressure
barium enema was done which showed distal bowel obstruction. Abdominal ultrasound was
done which also showed results suggestive of intussuception. They were advised surgery.
Review of Medications and Labs
No medications, multivitamins and supplements
Serum electrolytes: Hyponatremia
Temporal Profile
Review of Systems
General
fever weight gain weight loss weakness fatigue others
MSK/Integumenta rashes lumps sores itching muscle pains joint pains changes
in color joint swelling changes in hair/nails others
ry
headache dizziness blurring of vision tinnitus deafness
HEENT
epistaxis frequent colds hoarseness dry mouth gum bleeding
enlarged lymph node others
Respiratory
dyspnea hemoptysis cough wheezing others
Cardiovascular
palpitations chest pains syncope orthopnea others
nausea vomiting dysphagia heartburn constipation diarrhea
Gastrointestinal
rectal bleeding jaundice others
Endocrine
Genitourinary
Neurological

excessive sweating heat intolerance polyuria excessive thirst cold

intolerance others
dysuria sexual dysfunction discharge others
seizures tremors others

The review of systems is unremarkable.

Past Medical History
Family History

Family Genogram
Birth and Maternal History
Nutritional History
Immunization History
Developmental History
Motor
Lifts head
Rolls to one side
Crawl
Language
Babbles
Fine Motor
Grabs toy
Transfers objects from one hand to
another
Social
Smile
Stranger anxiety
Laugh
Personal, Social and Environmental History
Home
Education
Activity
Diet
Sexuality
Suicide
Spirituality
Stakeholders Analysis
Name/Role
Stake
Stand on
Intensity of
the Issue
Stand

Degree of
Influence

Insight/Action

Physical Examination
General Survey: Awake, alert, and not in cardiorespiratory distress.
Anthropometrics:
Weight: 34kg
Height: not taken
HFA: NA
WFA: NA
WFL: NA

HC:
CC:
AC:

Vitals Signs: BP: 90/60 HR: 69 bpm RR: 12 bpm T: 36.5 C

Head and Neck: Normocephalic, No CLADS, No neck vein engorgement. No lesions
in scalp
Eyes: Anicteric sclerae, Pink palpebral conjunctivae, No eye discharge, No periorbital
edema, No matting of eyelashes, Eyes are briskly reactive to light, (+) Red
orange reflex.

Ears: Ears are symmetric. Ear canal is non-hyperemic and tympanic membrane is not
bulging. No tragal tenderness. Visible cone of light bilaterally, with brownish
retained cerumen partially occluding the ear canals bilaterally.
Nose: Nasal bridge is flat, no alar flaring, nasal septum is midline, turbinates are pink
with no watery nasal discharge.
Oral Cavity: Dry lips, moist oral mucosa, hyperemic buccal mucosa and pharyngeal
walls. No tonsilar enlargement. Dental carries present. No gingival and
mucosal lesions.
Cardiovascular: Adynamic precordium, No heaves no thrills, Regular cardiac rate
and rhythm, Distinct heart sounds s1>s2 at the base, Apex beat at the 4 th ICS
MCL, No murmurs appreciated.
Chest and Lungs: Symmetric chest expansion, No retractions, No lesions or masses.
Clear breath sounds
Back and Spine: No lesions and obvious spinal deformities.
Abdomen: Flat abdomen, no distention, no scars, no masses, normoactive bowel
sounds and tympanitic on all quadrants, with epigastric tenderness (pain
scale= 5/10) but no organomegaly on palpation.
Pelvis and GU tract: N/A
Rectal: N/A
Upper and Lower Extremities: no obvious deformities, no lesions, no clubbing,
and no cyanosis. Full range motion of upper and lower extremities on active
and passive motion
Skin and Nails: No rashes, no lesions, no jaundice no cyanosis, good skin turgor.
CRT<2secs
Neurologic: Glasgow Coma Scale: 15, Cranial Nerves intact: (CN I: 2-3mm pupils,
EBRTL, CN III, IV, VI: (+) tracking, CN V: good suck, CN VII: no facial asymmetry, CN
VIII: gross hearing intact, CNIX,X: uvula midline, CNXI,XII: tongue midline)
Spontaneous motor movement of all extremities, vocalizes to pain, (+) Babinksi, (-)
Clonus, DTR: ++ on all extremities, No nystagmus, no nuchal rigidity
Salient Features
Pertinent Positives

Pertinent Negatives

History
Physical
Exam
Differential Diagnoses
Rule In

Primary Working Impression

Pathophysiology
Problem List
1.
2.
3.
4.
Plan
1.
2.
3.

Rule out

4.
Diagnostics
Therapeutics
Prognosis
Preventive Measures
Progress Notes
Date: 06/26/15
Age: 2yo
Weight: 7.9 kg
Height: 65 cm
BP: 90/60
HR: 128
RR: 38
Subjective
Objective
Visited at home
Microcephalic, Flat
Productive
cough occiput, Closed
and colds one week anterior and
in
duration, posterior
affecting
sleep, fontanelles, Eyes
relieved
by are asymmetric
salbutamol
and hyperteloric,
nebulization
Palpebral fissures
NO fever, vomiting slanted upward,
diarrhea or loose Prominent
stools
epicanthal folds,
Ears are low set
and symmetric, flat
nasal bridge,
NO CLADS
Regular cardiac
rate and rhythm,
no murmurs
appreciated
Pectus excavatum,
Asymmetric chest
expansion,
Presence of
Crackles, Ronchi
and inspiratory
wheezing on all
lung fields.
Suprasternal
retractions, No
lesions or masses.
Soft abdomen
normoactive bowel
sounds
Full and equal
pulses
Bilateral hypotonia
of lower
extremities

HC: 42.5 cm CC: 43 cm

AC: 44 cm
T: 36.6 C
Assessment
Plan
Recurrent Pediatric
Cefuroxime 2ml of
acquired
250mg/5ml every
pneumonia B
12 hours for 7
secondary to Down days.
syndrome with
comorbid
Mebendazole
Congenital Heart
chewable tablet
Disease with signs
of Congestive heart
failure and severe
malnutrition.
Intestinal
Parasitism

Date: 06/26/15
Age: 2yo
Weight: 7.9 kg
Height: 65 cm
BP: 90/60
HR: 128
RR: 38
Subjective
Objective
Visited at home for Pectus excavatum,
follow up
Symmetric chest
NO coughs and expansion, CLEAR
colds
Breath sounds, No
retractions, No
lesions or masses
Regular cardiac
rate and rhythm,
no murmurs
appreciated
Soft abdomen
normoactive bowel
sounds
Full and equal
pulses
Bilateral hypotonia
of lower
extremities

HC: 42.5 cm CC: 43 cm

AC: 44 cm
T: 36.6 C
Assessment
Plan
Recurrent Pediatric
Advise to continue
acquired
lanoxin tab and
pneumonia B
furosemide.
secondary to Down
syndrome with
Advice to follow up
comorbid
on 2D echo before
Congenital Heart
the end of July
Disease with signs
of Congestive heart Advise on hygiene
failure and severe
and sanitation and
malnutrition.
to look for danger
signs (persistently
high
fever,
difficulty breathing,
seizures, unable to
feed)

References:
Kliegman et. al. (2011) Nelsons Textbook of Pediatrics, 19th edition
Philippine Pediatric Society. (2008). Updates in the Evaluation and Management of Pediatric
Community Acquired Pneumonia.