MORNING

ENDORSEMENT
Bimbao, Figueroa, Villanueva
Junior Interns

CLMMRH
Department of Pediatrics
 GENERAL DATA
Name: C.D.
Age: 7 months old and 9 days
Sex: Female
Address: Brgy. Culipapa, Hinoba-an, Negros Occidental
Date of Birth: July 7, 2016
Religion: Roman Catholic
Nationality: Filipino
Informant: C.D.S
Relationship to Patient: Mother
Reliability: 90%
 CHIEF COMPLAINTS
Difficulty of breathing
Yellowish Discoloration
of the skin
 HISTORY OF PRESENT ILLNESS
Patient was born full term via NSVD, small for
gestational age at 2.2 kg. Born at a local district hospital
assisted by an OB-GYNE with no complications.
Patient was born to a G1P1 (1001) 31 year old mother
with regular prenatal check up starting at 5 months
AOG, with no maternal illnesses.

HISTORY OF PRESENT ILLNESS

At 4 months old
Folks noted generalized jaundice, icteric
sclerae, protuberant abdomen and acholic
stools.
Sought consult
Given request for ultrasound, complied.
 Ultrasound of Whole Abdomen

The liver shows a homogenous echo pattern and

texture. Negative for mass nor ascites. Unable to
visualize the gallbladder. The pancreas and spleen are
normal. Both kidneys show no stones nor callectasia.
The urinary bladder is echo free.
Remarks: To consider Biliary Atresia vs GB Agenesis.
Negative W/S of the liver, pancreas., spleen, kidney and
urinary bladder
 HISTORY OF PRESENT ILLNESS

Patient lost to follow up.

No meds taken.
 HISTORY OF PRESENT ILLNESS
At 7 months old:
Onset of fever and cough on the day of
consult with associated difficulty of
breathing.
 REVIEW OF SYSTEMS

General: (-)weight loss, (-) anorexia, (-) decreased level

of activity
Head, Eyes, Ears, Nose, Throat: (-) discharges
Cardiovascular: (-)cyanosis
 REVIEW OF SYSTEMS

Gastrointestinal: (-) constipation, (-) vomiting

Genitourinary: (+) dark yellow urine
 PAST PERSONAL HISTORY
Gestational history
Age of mother during pregnancy: 31 years old
Parity: G1P1 (1001)
No illness during gestation
Prenatal:
Prenatal check-up at 5 mos AOG at Local Health Center;
No history of infection or exposure to drugs or radiation
 PAST PERSONAL HISTORY
BIRTH HISTORY
Natal:
Full Term
Normal Spontaneous Delivery at a Local District Hospital
2.2 kg (SGA)
Post Natal:
Unrecalled APGAR Score, Spontaneous respiration
NBS done, normal results as claimed
(-) Jaundice, (-) Cyanosis
No feeding difficulties
No injuries or abnormalities
 PAST PERSONAL HISTORY

FEEDING HISTORY
Exclusive Breastfeeding until 1 month of age, shifted to milk
formula at 1 month to present
 PAST PERSONAL HISTORY
GROWTH AND DEVELOPMENTAL HISTORY
Gross Motor Fine Motor Hearing & Social Behavior
Speech
Rolls from front to Stretch both Responds to (+) strangers
back, cannot sit hands and grasp name anxiety
with support object
 PAST PERSONAL HISTORY

IMMUNIZATION
BCG 1 dose
DPT 3 doses
HBV 3 doses
OPV 3 doses
 PAST MEDICAL HISTORY

(-) previous hospitalizations

(-) blood transfusions, surgeries
(-) Allergies, Bronchial Asthma, Cardiac Diseases,
Pulmonary Tuberculosis
(-) Drug Exposure
(-) Radiation Exposure
 FAMILY HISTORY
Mother , 31 years old, apparently well
Father, 34 years old, apparently well

No heredofamilial diseases
 SOCIOECONOMIC HISTORY
Mother is a housewife
Father is a fisherman
Main source of income: from the fathers job
 ENVIRONMENTAL HISTORY

HOUSE: Mixed concrete and lightweight materials

WATER SOURCE: Mineral water for drinking
TOILET: Pour flush type
No exposure to chemicals, birds, radiation.
 PHYSICAL EXAMINATION

GENERAL SURVEY:
Awake, Spontaneous motor movement
Good cry and suck
 PHYSICAL EXAMINATION
PARAMETER PATIENTS RESULTS

Blood Pressure 80/50

Cardiac Rate 113 bpm

Respiratory Rate 29 cpm

Temperature 37 C

Oxygen Saturation 98%

 ANTHROPOMETRIC
MEASUREMENTS

WEIGHT: 5.2 kgs

HEIGHT: 56cm
Abdominal girth: 42.5 cm
 PHYSICAL EXAMINATION

SKIN
Generalized Jaundice
HEENT
Normocephalic; No hematoma, abscess or edema; No facial
asymmetry; Icteric sclerae, pinkish conjuntivae, pupils are
equally round and reactive to light and accommodation; No
nasal flaring; No nasal/ear discharges
 PHYSICAL EXAMINATION

NECK
Trachea is at midline; No lumps; No cervical
lymphadenopathies
 PHYSICAL EXAMINATION

CHEST AND LUNGS

Symmetrical lung expansion, occasional rales at bibasal area,
no retractions
CARDIOVASCULAR
Adynamic precordium; No visible pulsations; No palpable
thrills; point of maximal impulse located at 4th ICS LMCL;
Cardiac rate is regular in rhythm, no murmurs
 PHYSICAL EXAMINATION

ABDOMEN
Protuberant with girth of 42.5 cm, normoactive bowel sound . Dull
on percussion with areas of tympany. Liver is firm with liver span
of 5cm from the substernal line. (-) tenderness on palpation
INGUINAL REGION
No palpable masses and lymph nodes
GENITALIA
Grossly female genitalia
 PHYSICAL EXAMINATION

ANUS AND RECTUM

Patent anus
MUSCULOSKELETAL SYSTEM
Spontaneous movement
 PHYSICAL EXAMINATION

NERVOUS SYSTEM
MENTAL STATUS EXAMINATION- cannot assess
SENSORY- grasps finger when touched, change in facial
expression when touched.
CEREBELLAR- not assessed
DEEP TENDON REFLEXES- not assessed
 Cranial nerves
I: not assessed
II: regards face
II,III: blinks to light, (+) direct and consensual light reflex
III, IV, VI: tracts object
V: able to bite down
VII: cries with no facial asymmetry
VIII: turns to sound
IX, X: good suck and swallows
XI: not assessed
XII: symmetrical tongue protrusion when nose is pinched
 Laboratories
Exam name Result Normal values
Total Bilirubin 7.36 mg/dL 0.1-1.0 mg/dL
Indirect Bilirubin 2.64 mg/dL 0.1-0.6 mg/dL
Direct Bilirubin 4.72 mg/dL 0-0.4 mg/dL
Alkaline Phosphatase 878 U/L 39-117 U/L
SGPT/ALT 244 U/L 3-31 U/L
CBC Result Normal Values
Hematocrit 0.14 0.27-0.43L/L
Hemoglobin 44 85-145 g/L
RBC count 2.14 4.5-5.5 10^12/L
WBC count 13.9 4.5-11 10^9/L
segmenters 50 50-70%
lymphocytes 39 25-35%
monocytes 6 0-15%
eosinophil 5 1-5%
Platelet 162 84-478 10^12/L
 Chest X-ray

AP
Lateral