CASE PRESENTATION

PEDIA WARD

CHANDRU
SHAM
PADILLA
VEA

MD-3 B1
 GENERAL DATA
NAME O.J.
AGE 7 DAYS
SEX MALE
DATE OF BIRTH AUGUST 31, 2018
ADDRESS CABATACAN EAST, LASAM, CAGAYAN
NATIONALITY FILIPINO
# OF ADMISSION ONE (1)
DATE OF ADMISSION SEPTEMBER 2, 2018
TIME OF ADMISSION 6:30 PM
INFORMANT MOTHER AND FATHER (95%)

CHIEF COMPLAINT: Fever, convulsions

HISTORY OF PRESENT ILLNESS:
2 hours PTA, the parents of baby O.J. noticed that he had suddenly spiked a fever. They
also noted that his breathing sounded as if air is restricted and cannot pass thru the upper chest.
Furthermore, both the parents noted that Baby O.J.’s eyes were uncoordinated with the left
eyeball going up while the right eyeball going down.
Panicked, the parents reported this on the nurse on duty. The nurse then rushed baby
O.J. in the pediatrics ward, was given oxygen, and was then admitted.

PAST MEDICAL HISTORY:

According to the mother, Baby O.J. did not have any illnesses before. It was the first time
he suffered such conditions.
MATERNAL HISTORY:
Mother is 39 years old, G1T1P0A0L1 who claimed that she had monthly prenatal
checkup. Besides the fever she had during the first 1-2 weeks of being pregnant, she has no
other co-morbid conditions noted. She further said that during her pregnancy she mostly stayed
at home. She is not a smoker, alcohol drinker and illicit drug user. She said that she took calcium
and iron supplements given to her by their RHU.
BIRTH HISTORY:
The patient was delivered at term pregnancy via emergency Caesarean section on
August 31, 2018 due to preecalmpsia at Cagayan Valley Medical Center. During her stay in the
hospital, she was accompanied by her husband. The patient weighed 2.2 kg.

NUTRITIONAL HISTORY:
The patient is exclusively breastfed. The mother said that she breastfed Baby O.J. four
times on her first day.
IMMUNIZATION HISTORY:
According to the mother, the patient was given 1 dose BCG and 1 dose Hep B. The
patient’s immunization is complete for his age.
FAMILY HISTORY:
The mother of the patient is 39 years old, a housewife while the father is 32 years old
currently working as a construction worker. When asked about any medical conditions that is
present within their respective families, the mother said that his father had tuberculosis. The
father side, on the other hand, has no noted medical conditions. Furthermore, there is no history
of cardiovascular disease, cancer and diabetes.
PERSONAL AND SOCIAL HISTORY:
The patient is the first child of the family. The mother is 39 years old, a housewife while
the father is 32 years old working as a construction worker. He said that his work is their only
source of income. They live in a bamboo-walled, bungalow-type, one-roomed house with
galvanized roofing and their drinking water is tap water.
Since he was born on August 31, 2018, the patient stayed within the hospital beside her
mother until she was transferred to the pediatrics ward when he was admitted.

REVIEW OF SYSTEMS:
GENERAL Had fever, no change in activity level
SKIN No rashes, itching, lumps, dryness or color change.
HEENT No runny nose, no colds
RESPIRATORY No cough,
CARDIOVASCULAR No color change while feeding
GI No hematemesis, no diarrhea.
GU No dysuria,
MUSCULOSKELETAL
NEUROLOGIC
HEMATOLOGIC No easy bruising, pallor
PSYCHIATRIC

PHYSICAL EXAM
GENERAL: The baby is seen in white overall clothes, lying in bed. She is
awake, conscious and afebrile, has no obvious physical
deformities and at times, crying
VITAL SIGNS
BP:
HR: 138
T: 37.4
RR: 32
O2 Sat 97%
ANTHROPOMETRIC
MEASUREMENTS
Height 46 cm
Weight 2.2 kg
HC 34 cm
CC 33 cm
AC 33 cm
SKIN Skin is fair to reddish in color, smooth and warm to touch. No
jaundice noted, no cyanosis, no rashes/marks
HEAD,EYES,EARS, Normocephalic, no bulging fontanels, anicteric sclera, no oral and
NOSE,THROAT nasal discharge noted.
 CHEST and LUNGS LUNGS. Symmetrical chest expansion, no retractions noted, clear
breath sounds
HEART. Heart beat is normal rate and normal rhythm.
BREAST. 2 breast buds are observed.
ABDOMEN Globular with equal skin color, soft and non-tender umbilicus is dry.

EXTREMITIES Symmetrical extremities with no edema noted, extremities

maintain a posture of flexion.
NEUROLOGIC Presence of babinski and palmar grasp reflex when elicited.

DIFFERENTIAL DIAGNOSIS
SEVERE VIRAL INFECTION

GROUP B STREBTOCOCCUS NEONATAL INFECTION

Transient tachypnea of the newborn