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Informant: Mother and Step-Sister

Reliability: 90%
General Data
This is the case of M.S., 4 years old female, born on August 6, 2010, Roman Catholic from San
Miguel, Calasiao, Pangasinan. The patient was admitted for the first time at R1MC in the afternoon of
December 3, 2014.
Chief Complaint
Generalized Muscle Spasm
History of Present Illness
The patients present condition started one day prior to admission when the patient started
complaining of headache at the occipital area after playing outside their house. After a few minutes
patient started vomiting and the vomitus was described as dark brown in color, watery in consistency
with food particles with an estimated amount of cup. According to the sister, patient had 1 cup of
black coffee which the patient prepared by herself during breakfast.
After the vomiting, the step-sister suddenly saw the patient having generalized muscle spasm
with both arms extended, clenched fists and saliva was coming out of the patients mouth, the attack
lasted for 15 minutes. A mixture of banaba and breast milk was massaged onto the patients abdomen
in the belief that it would give relief due to the vomiting. The hands and feet were also massaged. Also
the patient was forced to vomit but failed in the belief that it would relieve the patients symptoms.
There were no other associated symptoms such as fever, cough, colds, dizziness, or abdominal pain.
Patient then was brought to the Emergency Room at Region 1 Medical Center where the patient
had 3 episodes of vomiting. Patient was also noted of having blank stares and giving delayed responses
to the attending physician, thus admitted.

Past Medical History


Prenatal History
- Patients mother did not have regular check-up on her first 3 months of pregnancy. There were
no medications taken during that period. On the 4th month of her pregnancy the mother went to
have her first check-up and she was diagnosed with hypertension and diabetes. The mother was
injected four times with unrecalled medication. Since then the mother went to have a check-up
every month. The mother was prescribed with vitamins (folic acid). On the 8 th month of pregnancy,
the mother was diagnosed with pre-eclampsia. The mother is a non-smoker and non-alcoholic
drinker.
Neonatal History
- Patient is pre-term, she was born on the 8th month of pregnancy to a 28 year old, G1P1 via
Caesarian Section at Region 1 Medical Center. There were no complaints of complications to the
patient or to the mother during and after delivery. Patients birth weight was 1.2kg with a good
APGAR score of 10/10. The patient was placed in an incubator for almost a month due to preterm.

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Post Natal History


- One week prior to admission, patient had non-productive cough with no other signs and
symptoms such as fever, chills, nausea, vomiting, runny nose, dyspnea or dizziness. Patient was
given Vitex Negundo (Lagundi) 5ml, 3 to 4 times a day by her mother without any consultation
done. There were no other medications given.
- Patient did not have any childhood illnesses such as measles, asthma, chickenpox, and pertussis.
The patient was given Multivitamins such as Tiki-Tiki given by their barangay health center
which was taken for only a few month. Ascorbic Acid (Ceelin) 1.5ml, once a day and Multivitamins
+ minerals (Nutrillin) 1 teaspoon, once a day which was given only for 5 months
- The patient had no accidents such as motor vehicular accident, head injury or trauma. There
were no surgical procedures done to. The patient has no known allergies to food or
medications.

Growth and Developmental History:


1 month smile
2 months good head control
3 months raises head, crawls, recognizes her mother
4 months rolls over
5 months first word mama
7 months gross motor movement, first tooth eruption
8 months sits with support
9 months stranger anxiety
12 months sits without support, stands with support
16 months stands without support
17 months walks with support; climbs stairs with both feet on same step
19months - walks without support
20 months - sentence construction, climbs stairs with one foot before the other
Significance: Growth and development is in par with the patients age.
Feeding History:
Patient was breastfed and sometimes with formula milk and consumes about 4 bottles a day
and was introduced to solid foods (Cerelac) at 7 months.
Family History:
- Patients mother is a 32 year old hair salon worker with a history of hypertension and epilepsy.
- Patients father is a 54 year old farmer with no known history of any illness or any familial
diseases.

Environmental

College of Medicine Department of Pediatrics

Patient lives in a semi-concrete bungalow house, which is located near the rice field,
approximately 10 kilometers away from the city proper. The house has 4 bedrooms with 1 bathroom
(flush type). The patient studies at a day care center and is fetch by her mother. Patient is active at
school by participating in activities or recitations. She sometimes quarrel with her younger brother,
which always end up having the patient cry so much and have episodes of breath holding spells with no
noted muscle spasm, jerky movements or other symptoms of seizure. Patients younger brother had
colds and her classmate had cough. They also have pets such as dogs and cats. And theyre also taking
care of goats, chicken, and carabao. Patient is fund of playing around and lying down on the rice field.
The Patient prefers eating vegetables, fish, noodles and eggs. The source of water is from deep well and
garbage is disposed by burning it near their house, There were no smoker in theeir household. Patient
had no known exposure to chemicals such as pesticides or fertilizer.
Review of Systems
General

Body weakness
Fatigue

Wt. loss
Chills

Skin

Jaundice
Pallor
Urticaria

Hematoma
Cyanosis
Signs of
dermatologic
or bleeding
Stiffness

Head & neck

Eyes

Ears
Nose
Throat
Neck
Breast
Respiratory

Cardiac

Nodules or
hematoma
Pain
Trauma
Asymmetry
Infection
Icteric sclera
Itchiness
Blurring of vision
Redness
Hematoma
Hearing loss
Tinnitus
Infection
Discharge
Failure of smell
Discharge
Sneezing
Dryness
Bleeding gums
Sore tongue
Hoarseness
Dysphagia
Lumps
Pain
Lumps
Pain
Cold
Cough
Hx of exposure to resp. occupational
hazard
Chest pain
Edema

Easy fatigability
Fever

Sweats
- Decrease
appetite
Sores
Pruritus
Lesions
Rashes
Abnormal pigmentation

Swelling

HA

Alopecia
Pain
Corrective lenses
Lacrimation

Dizziness
Diplopia
Glaucoma
Cataract

Pain
Vertigo
Itching
Obstruction
Dry mouth
Dentures
Stiffness
Discharge
Hemoptysis
Shortness of
breath
palpitations

Hearing aids
Nosebleeds
-

Sore throats
Infection
Masses

Dyspnea
Pain

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Dyspnea
3

Orthopnea

GIT
-

GUT

Dysphagia
Loss of appetite
Black tarry stool
Polyuria
Hematuria
Deformities
Masses
Dizziness
Tremors

Musculoskeleta
l
Neurological

Paroxysmal
nocturnal
dyspnea
Heartburn
Abdominal pain
Excessive
belching
Anuria
Urgency
Pain
Change in strength
Slurred speech
Convulsion

Lethargy
Heat tolerance

Endocrine

Hematological
Emotion

Cold
intolerance
Polydipsia
Easy bruising
Hematoma
Insomnia
Hallucination

Polyphagia
Anemia
Pallor
Anxiety
Ideation

Syncope

Easy fatigability

Nausea
Diarrhea
Bloody stool

Vomiting
Constipation

Nocturia
Frequency
Stiffness

Dysuria
Incontinence
Fatigue

Seizure
Loss of
consciousness

Paralysis
paresthesia

Excessive
sweating
Nocturia
Bleeding

Polyuria

Depression

Suicidal

Petechiae

Physical Examination
General Survey
The patient was awake, conscious and coherent. Patient was oriented to the place and person.
Patient was playing throughout the whole interview.
Vital Signs:
Parameters

Values

Blood Pressure

90/70 mm Hg

Respiratory Rate

27 cycles per minute

Pulse Rate

114 beats per minute

Temperature

36.7C

Reference Range
SBP: 95 to 110 mm Hg
DBP: 60 to 75 mm Hg
20 to 25 cycles per
minute
65 to 110 beats per
minute
37C

Interpretation
Normal blood pressure
Normal respiratory rate
Normal pulse rate
Normal body
temperature

Anthropometric Measurements:

Height/Length: 94.5cm

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Head Circumference: 47 cm

Chest Circumference: 51cm


Abdominal Circumference: 48 cm

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Weight: 12kg
Ideal Body Weight: 16 kilograms

**Patient is underweight
Skin:
The patient is warm to touch with normal skin turgor and normal capillary refill time. She has
pink nail beds. There is no pallor, jaundice, or cyanosis and no suspicious nevi or petechiae.
HEENT:
Head: Patients hair is of average texture and is evenly distributed. No scars, trauma, or
malformations noted.
Eyes: Patient has anicteric sclera and pink palpebral conjunctiva. There are no discharges, crusts,
sunken eyeballs, or edema noted.
Ears: There are no discharges, mass or tenderness noted.
Nose: There are no discharges or septal deviation.
Mouth/Throat: Patient has pink oral mucosa with no bleeding, mouth sores, enlargement of
tongue or enlargement of tonsils.

Neck:
There is a small, moveable, non-tender nodule palpated in the submandibular region.
College of Medicine Department of Pediatrics

Chest and Lungs:


The symmetric expansion of chest on both sides is normal. Tactile fremiti on palpation and
resonant on percussion on both sides. Upon auscultation, vesicular breath sounds were noted throughout
the lung fields on both sides. No extra breath sounds such as crackles and wheezes noted.
Heart:
Adynamic precordium. The PMI is noted at 5th ICS slightly of the left midclavicular line.
No palpable thrill.
Normal rate and regular rhythm.
No murmurs heard.
Abdomen:
Patient has flat abdomen with normoactive bowel sounds and tympanitic on percussion. No
tenderness or mass noted on palpation.
Extremities:
No atrophy, gross deformities, edema, or masses noted. It is warm to touch with strong equal
peripheral pulses.
NEUROLOGIC EXAM :
Cerebrum : conscious, Glassgow Coma Scale of 15, Eye=4 Verbal=5 Motor=6

oriented to time, place, name

Neurologic Examination:
CN 1 normal olfactory functioning (can smell)
CN 2, 3 pupils equally reactive to light
CN 3, 4, 6 normal and intact extraocular muscles
CN 5 normal corneal reflex on both eyes
CN 7 no facial asymmetry (can smile, frown, close and open eyes) ; no flattened nasolabial
folds, intact sense of taste
CN 8 no hearing loss on both ears
CN 9, 10 intact gag reflex
CN 11 can shrug shoulders
CN 12 tongue at midline on protrusion
Pathologic reflexes: (-) Babinskis sign, (-) Kernigs sign, (-) Brudzinski sign, (-) nuchal rigidity

College of Medicine Department of Pediatrics

Subjective:
o Headache at occipital area
o Generalized muscle spasm
o Vomiting
o Patient was born pre-term
o The mother had pre-eclampsia.
o Family history of epilepsy
Objective:
o Changes in sensorium (blank stares and delayed responses)
o Underwieght
Assessment:
Generalized tonic seizure.
Plan:
o
o
o
o

To achieve a seizure-free status


Neuroimaging evaluation: CT Scan, MRI and EEG
Lumbar puncture
Supportive therapy.

Differential Diagnosis:
1. Meningitis
2. Absence Seizure
3. Partial Seizure

College of Medicine Department of Pediatrics

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