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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.
Environmental
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
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
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
Pulse Rate
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
Head Circumference: 47 cm
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
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
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
Differential Diagnosis:
1. Meningitis
2. Absence Seizure
3. Partial Seizure