1) MEDICAL HISTORY Patients Name: Xhian Sarroza Informant: Mother Reliability: Good General Data Birthday: 08/10/2010 Age:

e: 1 year and 9 months 5 days Address: zone I Dasmarinas, Cavite Born in: Salitran Lying IN clinic Born again 1st time admitted last Tuesday (05/22) @ 4pm CC: Seizure HPI: 1 day PTA had a fever episode (39C) of sudden onset, mother gave tepid sponge bath, and paracetamol drops 1.25 ml every 4 hours, fever subsided. Within the day - Fever episodes were intermittent, no loss of appetite but patient would vomit everything he eats nanghihina 4 hours prior to admission, fever remained @ 39C with a seizure episode of short duration (nangisay pero very saglit lang), mother continued sponge bath with ice, and gave paracetamol with the same dosage, Few mins PTA, fever peaked @ (40C) with another seizure episode (duration was not recalled, caregivers were already panicking) was noted. grand mother noticed the ff: o Upper and lower extremities were stiffened and extended (isipin nag seizure nga eh!) o Back was arched upward o Backward rolling of the eyes o Tuloy tuloy na nangingisay, kaht na hawakan mo na.. Which prompted immediate hospitalization

PMH

Maternal/birth hx 26 y/o mother, G1P1 (1001), delivered via normal spontaneous vaginal delivery w/o complications during labor and delivery; px was not in any physical distress and was immediately discharged Prenatal regular checkup @ bgry HC; took multivitamins and ferrous sulfate as advised; diet consisted of meat, fried food, and preserved goods (eg. Hotdog); no changes in appetite or weight were noticed; no vices such as alcohol and smoking Natal 1st child; birth wt approx 3000lbs Hospitalization/childhood illnesses o no other major hospitalizations o Had bronchitis last Jan 2012 (4 mos ago) o Had 2 episodes of tonsillitis (1st November 2011; 2nd April 2012) No allergies Feeding hx o Since birth, px was breastfed for 2 wks then shifted to bottlefeeding (Bona S1) o Bona S1 for 6 months; consumed 4 bottles (3oz/bottle) within the day o Feeding increased eventually (#bottles consumed were not noted) o From Bona s1, px was shifted to Anchor for 3 mos Nido (3mos) Bear brand (present); consumes at least 5 bottles (222ml)/day Growth and Devt (milestones) o @ 6mos tooth eruption began (central incisors)

 Family HX

@ 8mos able to sit upright; able to say two-syllable words (eg. Mama) @ >12mos able to stand and walk in a walker @ 21 mos able to run around (very makulit); able to combine two-syllable words in a meaningful sentence; usually picks up objects/food (eg. Biscuits) with pincer grasp; able to feed self with biscuits; able to point at people when asked to identify (hal. Mom sinong kaaway mo? then baby points at anna); pag binigyan mo ng object at ni-try mong ipahawak sa kamay na may hawak pa, ittry niyang kunin yung inaabot mong object with the vacant hand; follows one-step command without gestures; pacified when given an object to play with; able to distinguish primary caregivers (mother, lola, tita) from strangers; prefers to be carried by mother most of the time; tooth eruption (2 molars, mandible part); currently has 8 teeth (4 sa taas, 4 sa baba) Immunizations complete (yung included sa EPI program ng DOH kasi sa HC sila nagpapabakuna)

o o o

(+) asthma and hypertension, maternal side Convulsion episodes were also noted among the pamangkins (age not specified), paternal side

ROS (Pertinent) Skin small wound scars over dorsum of left hand; erythematous macules (insect bites) over dorsal aspect of left foot Respiratory currently has cough with whitish phlegm (duration not asked) GIT/GUT bowel movement: 1x/day usually in the morning with firm consistency and yellowish in color; frequent urination within the day, no difficulty; no toilet training yet! Nutrition multivitamins were given for 2 mos since birth then stopped resumed multivitamin intake @ 12 mos, which only lasted for a month, then stopped (kasi niluluwa ng baby) Other organ systems are unremarkable

2) PHYSICAL EXAMINATION General appearance: px appeared to be active during examination; played a lot with the tita and mom; would cling on to mother when approached by examiner; with good eye contact; with endomorphic built; with IV line splinted at R hand VS: o Temp: 36C o HR: 122 bpm, regular, (-) murmurs/bruit o RR: 56 cpm Anthropometric measures: o HC: 44cm o Chest circ: 45cm o Abdomen: 51cm o Height: 95cm o Weight: 10.5kg Skin: fair-skinned; smooth, with good turgor, lesions check ROS; (-) masses, discolorations; (-) clubbing, cyanosis of nails; good capillary refill; Hair black, evenly distributed, no parasitic infestation Head: fontanelles were not assessed (baby was irritated); normocephalic; (-) masses, lesions; symmetric facial features Eyes: symmetrical; (-) external lesions; follows moving objects; other parts not assessed kasi px was crying Ears: normoset ears; (-) lesions in the pinna; follows direction where sound/name is heard; other parts not assessed kasi px was crying Nose: no external lesions noted; nares symmetrical; (-) alar flaring noted; other parts not assessed kasi px was crying

Neck: (-) stiffening, full range of movement, (-) palpable cervical/submandibular/submental/periauricular lymph nodes; trachea is in the midline; thyroid gland not assessed (baby was irritated) Chest and Lungs o Symmetrical chest expansion; (-) external masses/lesions; (-) thoracic deformities o (-) intercostal retractions o Abdominal breather o Bronchovesicular sounds heard mostly over the bilateral upper lung fields; (+) rales? (basta malakas but not bronchovesicular, would indicate na may phlegm over that lung field) best heard over right lower lung field o Percuss/palpate not done Cardiovascular o S1=S2 auscultated directly below areola of the nipple (paki-research na lang kung anong ICS to) o No other abnormal heart sounds were heard upon auscultation o Inspection (what to document for pedia px paki-research na lang) Abdomen o Slightly distended (just imagine yung usual tiyan ng baby), soft in consistency, fair-skinned, (-) scars, masses, lesions; umbilicus is inverted o Normoactive bowel sounds all over abdomen; 4/min, best heard over R iliac region/RLQ Musculoskeletal o (-) deformities o With good tone and strength (5/5) able to raise extremities against gravity and against resistance Neurologic o Cranial nerves: Full EOMs intact III, IV, VI Follows moving objects and responds accordingly intact II With full facial expression (smiles, cries, stares) intact VII Sticks out tongue intact XII Raises shoulders/ full upper extremity ROM intact XI No difficulty with swallowing intact IX, X o Reflexes: No pathologic reflexes observed Paki-check na lang yung dapat na wala sa kanya, kasi reflexwise ok naman siya.