FAR EASTERN UNIVERSITY

DR. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER

Regalado Ave., Corner Dahlia Street, West Fairview Quezon City 1118
Telephone Number: 427-02-13

DEPARTMENT OF CHILD HEALTH

CLINICAL HISTORY
DATE: May 16, 2016
INFORMANT: Mother
RELIABILITY: 80%
GENERAL DATA:
Alfonso, Ayessa Nicole Panal, 6 years old, Female, Filipino, Roman Catholic, born on June 26, 2009 in
Cabanatuan City, currently residing at Lot 3 Block 6 Sevilla Street, Summerville Subdivision,
Mayamot, Antipolo City, admitted for the 14th time in FEU-NRMF Medical Center on February 21, 2016.
CHIEF COMPLAINT: For intrathecal chemotheraphy
HISTORY OF PRESENT ILLNESS:
The patient is a diagnosed case of Acute Lymphoblastic Leukemia FAB L1 since January
2014, when the patients grandmother noticed petechial rashes on her lower extremities associated
with dizziness. No accompanying symptoms such as fever, body malaise, diarrhea or abdominal pain.
The grandmother also noted a 5-6cm hematoma on her right lower knee. The patient also had
difficulty climbing stairs when the grandmother noticed her with difficulty of breathing when using
the stairs. She was brought to a private paediatrician and was referred to a Pediatric Hematologist,
she was then diagnosed with Acute Lymphoblastic Leukemia. Induction phase of 28 days was started.
She was given Vincristine 1.5mg/ml IV, Prednisone 40mg/ml PO, L-asparginase 6,000u/ml and IV
Methotrexate 12 mg was started. She was also diagnosed with Mulluscum Contagiosum and was
given Salicylic acid cream, applied twice a day after bathing and Mupirucin topical ointment on
affected areas which afforded temporary relief.
On March 18, 2014, patient was admitted for the 2 nd time in our institution for
chemotheraphy, stayed in the ward for 2 days and was given intrathecal Methotrexate 12mg, 6Mercaptopurine 50mg/tab tab at bedtime, Cotrimoxazole suspension 400mg/80mg/5ml, 5ml every
12 hours, Nystatin syrup 1ml gargle, Mupirucin ointment applied to affected area 3 times a day,
Miconazole oral gel applied to affected area 3 times a day, Imiquimod cream 5% at bedtime Monday
to Friday for 2 months.
She was admitted last May 24, 2014 when she completed her delayed intensive phase
treatment with Vincristine 1.2mg IV push, Doxurubicin 20mg + 100cc D 5W to run for 30 minutes,
Dexamethasone 4mg/tab 2 tabs once a day after full meal, Al(Mg)HO3 2 tsp 20 minutes after meals
after bedtime, Cyclophosphamide 840mg + 250cc D5W to run for 2 hours, Cotrimoxazole suspension
400mg/80mg/5ml, 5ml every 12 hours, Nystatin Syrup 1ml gargle, Mupirucin ointment applied to
affected areas 3 times a day, Miconazole oral gel applied to affected area 3 times a day.
She was admitted on September 21, 2015 for single intrathecal chemotheraphy of
Midazolam 5mg TSIV 30 minutes before intrathecal procedure, Ketamine 25mg TSIV before
intrathecal procedure, Methotrexate 12mg and Vincristine 1.2mg TSIV. She was continued to 6Mercaptopurine 75mg/tablet, 1 tablet once a day from Monday to Saturday, complete blood count
with platelet count, cerebrospinal fluid total count and differential count and ASO were done which
revealed normal results.

Patient was seen in FEU-NRMF OPD on November 16, 2015, with a diagnosis of URTIBacterial, and was given Cefuroxime at 3.8 mg/kg/day BID for 10 days and Loratidine +
Phenylephrine syrup 6.5ml CID for 5 days.
Patient was admitted at FEU on February for the 13th time at FEU-NRMF Medical Center for
scheduled intrathecal chemotherapy. Patient was continued with Clatithromycin 250mg/5ml, 4ml
twice a day for 4 more days, oral medications such as DMP, Methotrexate and Prednisone were also
continued. Patient had dome shaped centrally umbilicated papules on several areas of the body,
particularly on the lumbar area, elbows , knees and face. She was started on Phenylephrine HCl +
Brompheniramine maleate (Remedril) 5ml, three times a day for 5 days. Other medications were
continued. Intrathecal Metothrexate and Vincristine were tolerated well.
On March 2016, patient was admitted for urinary tract infection. Patient was started on
Ceftriaxone 650mg TSIV ANST every 12 hours, Citirizine, 1mg/ml 5ml once a day for 7 days.
At present, patient has good activity, good appetite. Patient had a single episode of
projectile vomiting of previously ingested food amounting to 1 cup, non-bilous, non-bloody. No
subjective complaints of dizziness, headache, fever, abdominal pain and diarrhea.
PAST MEDICAL HISTORY
2009, the patient was diagnosed with Ileus, was admitted at a private hospital in
Cabanatuan City,
given unrecalled medications and discharged after 3 days. No known complications.
2013, had varicella with no known complications. No other childhood diseases such
as measles, mumps and primary tuberculosis
2013, also diagnosed with bronchial asthma and was given Salbutamol nebulisation,
as needed for difficulty of breathing. Last attack was on January 2014
Patient had approximately 6-8 times of cough and common colds per year lasting for
3-5 days.
Known allergic to L-asparginase, no known allergy to food or drugs.
No history of major trauma, no history of surgical procedures.
FAMILY HISTORY
Father: Bart Alfonso, 32 years old, car insurance agent, apparently well
Mother:Theresa Panal Alfonso, 32 years old, car insurance agent, apparently well
Siblings:

10 year old, male apparently well

6 years old, female patient
5 year old, male- apparently well

Herdofamilial diseases:
Hypertension- Father and mother side
Pulmonary tuberculosis mother side
IMMUNIZATION HISTORY:
VACCINES
BCG
Hepatitis B
DPT
Hib

DOSE
1 (at birth)
3
3
2

PLACE
At a private
At a private
At a private
At a private

clinic
clinic
clinic
clinic

OPV
Measles
Pneumococcal
Rotaviru

3
1
1
1

At a private clinic
At a private clinic

NUTRITIONAL HISTORY
Patient was on mixed feeding from birth up to 2 years of age. She was started on S26
formula milk up to 6 months with 1:1 dilution, consuming 3-4 ounces per day. Complimentary food
was started at 6 months. There was no encountered difficulty of feeding. Presently she consumes
about 3-8 spoonfuls of rice with viand.
DEVELOPMENTAL MILESTONES
Age

Gross

Fine

Language

Birth

Fixate face or light

in line; dolls eye
on turning
Follows
objects
180 degrees
Sits briefly with
support
Walks alone
crawls upstairs

N/A

N/A

N/A

Coos

Transfer
objects
hand to hand
Makes line with
crayons
Inserts pellets in
bottle
Tower of 9 cubes

Polysyllabic vowel
sounds formed
Jargon
Follows
simple
commands

8 weeks
28 weeks
1 year old

2 year old

4 year old
5 year old

Runs well
Walks
up
downstairs

and

Hops on one foot

Climbs well
Throws well
Skips
Dress and undress
Brushes teeth

Copies cross and

square
Copy
triangle,
circle and square

Knows age and

sex
Counts 3 objects
correctly
Counts 4 coins
accurately
Tells a story
Speak
clearly
using
more
complex
sentences

Personal
Social
N/A

and

Smiles on social
contact
Prefers mother
Enjoys mirrors
Hugs parents
Indicates
some
desires or needs
pointing
Plays
simple
games
Washes hands
Plays with several
children
Enjoys
playing
with other children
Shares and takes
turns

PERSONAL SOCIAL HISTORY:

She is a product of a planned pregnancy. She usually sleeps for 9-12 hours a day. She drinks
5-6 glasses of water a day. She lives in a well-lit, well ventilated, semi-concrete 2 storey house. With 8
household members consisting of her father, mother grandmother, aunt and 2 brothers. Water for
general use is supplied by Maynilad and water for drinking is purified water. Her grandfather is a 3
year pack smoker. Garbage is collected 2 times a week, non-segregated
PHYSICAL EXAMINATION UPON ADMISSION:
GENERAL SURVEY: Conscious, coherent not in cardiorespiratory distress, with no signs of some
dehydration.
BP 90/60
HR 103 bpm
RR 24 cpm
Temp 36.5 C
O2 Sat: 97%
Weight: 24 kg
Length: 110 cm
BMI: 19.83 kg/m2
IBW: 20.0 kg

HEENT: Pink palpebral conjunctiva, white sclerae, intact tympanic membranes, moist lips and moist
buccal mucosa, with pink pharyngeal walls
NECK : Supple, No palpable lymph nodes, no palpable masses
LUNGS: Symmetrical chest expansion, no retractions, clear breath sounds, good air entry
HEART: Dynamic precordium, tachycardic, regular rhythm, no murmurs
ABDOMEN: Soft, flat, with normoactive bowel sounds, non-tender, no masses, no organomegaly
EXTREMITIES: No gross deformities, full and equal pulses, CRT <2 seconds
SKIN: good skin turgor, with dome shaped centrally umbilicated papules on several areas of the
body, particularly on the lumbar area, elbows , knees and face
NEUROLOGIC EXAMINATION
Cerebrum: Conscious, Coherent, with a GCS 15 (E4, V5, M6) Oriented to time, place, and person.
Intact immediate, recent, remote memory.
Cerebellum: No nystagmus, with unsteady gait, was able to do rapid alternating movement.
CRANIAL NERVES:
I
Intact smell
II
2-3 mm equally reactive to light
III, IV, VI
Intact extraocular muscles
V
Was able to clench teeth, with corneal blink reflex
VII
No facial asymmetry, can smile, frown, able to puff cheeks
VIII
Intact gross hearing, able to balance
IX, X
With gag reflex, uvula at midline, clear phonation
XI
Can shrug shoulders, was able to turn head from side to side
XII
Tongue at midline
Motor function

5/5

Sensory function

5/5

5/5

5/5

100%

100%

DTR

100 %

100%

++

++

Signs of meningeal irritation: No nuchal rigidity, No Kernig sign, No Brudzinski sign

Reflexes: (-) Babinski, (-)Brudzinski, (-)Nuchal rigidity
ASSESSMENT:
Acute Lymphoblastic Leukemia
PLAN OF CARE:

++

++

Please
admit
to
service
ward
under
Rondilla/Dacula/Genuino/Pangilinan/Aquino/Angeles
Diet as tolerated
For complete blood count with platelet done
For urinalysis
For intrathecal chemotheraphy Metothrexate tomorrow
Hold oral Metothrexate on Sunday
Weigh patient now then daily and record
Monitor vital signs every 4 hour and record
Monitor input and output every shift and record
Refer accordingly.

the

service

of

Dr.

Dr. Rondilla/Dacula/ Genuino/ Pangilinan/ Aquino/

Angeles/

JIIC Tolentino/Co-JIIC Victoria / Co- JIIC Vicaldo