Salazar, Nim Franzio II A.

AUP College of Medicine

Batangas Medical Center
Department of Pediatrics
Pedia-Ward

Case Presentation

I. IDENTIFYING DATA
Informant: Father
Reliability: 80%
J.C.O., 5 months old, male, born on December 4, 2018. Resides at Sitio Barrera, Barangay Lecheria, Calamba, Laguna.
First time to be admitted at Batangas Medical Center on May 30, 2018 at

II. CHIEF COMPLAINT

Cough of 3months persistence associated with difficulty of breathing

III. HISTORY OF PRESENT ILLNESS

3 months PTA when the patient experienced the 1st episode of cough that was noted to be non-productive. No other
associated symptoms such as fever, colds, and vomiting. Ambroxol drops of unrecalled dosage and frequency was given to the
patient by his mother which provided relief. No consult was done.
The patient was noted to have occasional coughs until 1 month PTA, he experienced another episode now noted to be
productive, whitish in color and with difficulty of breathing. Ambroxol was again given to the patient by his mother which provided
temporary relief. The symptoms persisted for 1 week however no consult was done during this time.
3 weeks PTA, the mother of the patient sought consult for her follow up at private clinic, bringing with her the patient. Upon
examination of the mother, the doctor noticed that the patient was cyanotic and having difficulty of breathing. She was
immediately advised to bring the patient at the emergency department of Jose P. Rizal Memorial Provincial Hospital. The patient
was given immediate (unrecalled) treatment and was eventually admitted with the diagnosis of Pneumonia. The patient was
admitted from May 7 to May 24 (2weeks and 3 days). Laboratory tests showed: Blood CS negative; CBC increased wbc and
lymphocytes; Na & K normal.
During his admission at the JPRMPR Hospital, the patient developed fever documented at 38’C. Paracetamol drops 10
mg/kg/dose was given every 4 hours which provided temporary relief. Co-amoxiclav, Salbutamol, Hydrocortisone, Ranitidine
was also given. The patient improved and was eventually discharged. He was Advised to continue Salbutamol neb and 1
unrecalled antibiotic medications at home.
Symptoms persisted until 1 day PTA, the patient had difficulty of breathing and was noted to be cyanotic by his mother.
Salbutamol was given which provided temporary relief.
Few hours PTA, the patient was brought for a consult at a private clinic due to the persistence of symptoms. Consequently,
they were advised to bring the patient to Batangas Medical Center. Hence, admission.

IV. PAST MEDICAL HISTORY

No previous injuries or accidents, surgeries, asthma and allergies to food and drugs.

V. BIRTH HISTORY
Patient was born with the birthweight of 12.1 lbs, full term, via non-institutional normal spontaneous delivery to a 37 year
old G4P4 (4004) with good cry and activity, assisted by a midwife at home. No feto-maternal complications were noted.

VI. MATERNAL HISTORY

The mother of the patient had irregular check-ups at a private clinic during the course of pregnancy. No noted maternal
illnesses.

VII. FAMILY HISTORY

Father is a known hypertensive.
Mother diagnosed with asthma.
No family history of heart disease, stroke, cancer, and tuberculosis.

VIII. IMMUNIZATION HISTORY

IX. GROWTH AND DEVELOPMENT

X. FEEDING HISTORY
Patient was not breastfed and was immediately started on formula milk (Bona) at 2 ½ scoops given at 4-6x/day.
Complimentary feeding was eventually introduced at the 5th month with porridge and biscuits.
Salazar, Nim Franzio II A.

XI. SOCIAL AND ENVIRONMENTAL HISTORY

Mother is 37 year old, non-smoker/alcoholic drinker, high school graduate, currently working in LTO as?
Father is a 35 year old, occasional smoker and alcoholic drinker, high school graduate, works as a helper.
Patient is the youngest among the 4 siblings. 1st child – 9 year old, 2nd child – , 3rd child -
House/Occupants: 6 occupants with well-ventilated house.
Mineral water as primary drinking source.
Garbage is disposed through regular city garbage collection.
Pets: Dog
Pollution: (+) exposure to smoke from father who smokes and coal used for cooking.
TB Exposure: Patient was repeatedly exposed to a known PTB patient – neighbor.

XII. REVIEW OF SYSTEMS

General: No weight loss, fever and chills
Skin: No rashes
HEENT: No eye, ear and nasal discharge, No gum bleeding, no neck lumps
Musculoskeletal: No joint pain nor swelling
Cardiovascular: No palpitations nor cyanosis
Gastrointestinal: good appetite, no diarrhea, no bloody stool, 3 full diapers used/day with noted soft stools.
Genitourinary: No dark or bloody in urine
Neurologic: No seizures

Salient Features:

XIII. PHYSICAL EXAMINATION

General Survey: awake, comfortable, in mild cardiorespiratory distress with following vital signs:
CR: 165 bpm, regular
RR: 32 cpm
Temp: 37.6
O2 Sat: 89 – 95%
Weight: 6.8 kg
Height: 149 cm

XIV. SALIENT FEATURES

5 months old

XV. DIFFERENTIAL DIAGNOSIS

XVI. PRIMARY IMPRESSION

Pneumonia Moderate Risk with Hyper-reactive Airways; T/C Primary Complex

XVII. COURSE IN THE WARDS

XVIII. MANAGEMENT