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Betua

Prince Angel Espinosa Betua is a 4-month-old male who presented with difficulty breathing, productive cough, and loose stools for 2 weeks. He has a history of pneumonia and was previously hospitalized for 20 days. On examination, he was in respiratory distress with coarse rales and retractions. He also had a floppy extremity and hypotonic muscles.

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35 views3 pages

Betua

Prince Angel Espinosa Betua is a 4-month-old male who presented with difficulty breathing, productive cough, and loose stools for 2 weeks. He has a history of pneumonia and was previously hospitalized for 20 days. On examination, he was in respiratory distress with coarse rales and retractions. He also had a floppy extremity and hypotonic muscles.

Uploaded by

Samuel
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We take content rights seriously. If you suspect this is your content, claim it here.
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CLINICAL ABSTRACT

Name: BETUA, PRINCE ANGEL ESPINOSA Age: 4months/Male Date of Birth: 01/03/2019

Address: Sitio Ruhat Purok III, Brgy Mambugan, Antipolo City

4.9 kg/58cm

Cc: difficulty of breathing

A> PCAP C, atopic dermatitis

History of Present Illness

2 weeks prior, patient was noted to have productive cough with thick secretions and watery nasal
discharge. No fever. No changes in appetite and activity.

IH, persistence of cough and colds.

1 week prior, patient was seen at pulmo opd. CXR and PPD were requested as outpatient. A>
pneumonia. Patient was given Amoxicillin at 45 mkd for 7 days.

IH persistence of cough and colds

3 days prior, still with cough and colds. Patient noted to have increased rate of breathing. Still no fever.
No changes in appetite and activity. Noted to have loose stools, mucoid, approximately 2x/da. Patient
was observed only. Amoxicillin continued

IH, increasing frequency of loose stools with persistent cough and colds. Noted increasing respiratory
effort as well.

DOC, patient noted CXR results of pneumonia. Seen at OPD then advised ER consult.

Past Medical History

Patient previously admitted from 3/07 to 3/26 s/p intubation and admission at PICU for 20 days. A>
pneumonia severe, atopic dermatitis, HCAI. Given ceftriaxone and piptazo. THM physiogel,
multivitamins, and dibencozide. Pierre robin syndrome was initially considered but ruled out. NBS
normal results

Birth and Maternal History

Born to a 28 y.o. G2P2 (2002) NS NABD cognizant of pregnancy at 2 mos with RPNCU at Padilla Hospital
c/o OB. Treated with multivitamins, feso4, folic acid, calcium with good compliance. Bleeding at 3 mos
but no meds given. Spotting resolved with rest. No other maternal illness. No exposure to viral
exanthem or radiation. Ultrasound done at 6mos with normal findings. Ultrasound done at 9 mos
noted decreased water.

Delivered FT at 40 wks via emergency CS at Padilla hospital c/o OBdue to fetomaternal distress. Patient
noted to have good suck and cry. NBS and HS not done. BM and UO within first 24 hrs. BCG and Hep B
given. Vit K and erythromycin ointment given. Discharged after 3 days.

Immunization History

Bcg x 1

Hep b x 1

Pentahib x 1

OPV x 1
Nutritional History

Exclusive breastfeeding

Given Nan formula occasionally (2oz)

Social history

Lives with both parents, 4y.o. sibling, and aunt. Father noted to have pneumonia and PTB, currently
on 1 wk of HRZE treatment. Grandmother and sibling with cough and colds as well.

Growth and Development

Patient was initially noted to have floppy extermities at the 1st week of life.

Coos x 1 month

No head controlat 3 months AOG

Physical Examination

Awake alert in distress

36.9 190s 97% 60 70/40

Flat non sunken fontanelles

Anicteric sclera, nonsunken eyes, moist lips and oral mucosa, Watery nasal discharge, no clads, no alar
flaring

Symmetric chest expansion, (+) coarse rales, shallow SC and IC retractions

Adynamic precordium, tacchycardic, regular rhythm

Soft abdomen, nondistended, no organomegaly

FEP, warm extremities

Abscess, R shoulder ( vaccination site)

Floppy extremities

Neurological Examination

Awake alert with good regard with intact visual tracking

Cranial Nerves

I - Not assessed

II - Pupils briskly reactive to light and accomodation (3mm), no facial asymmetry

III, IV, VI - no facial asymmetry

V, VII

VIII - turns to sound, gross hearing intact

IX X - good suck

XI - no neck tonicity

XII - able to swallow, tongue midline

Motor
Hypotonic extremities

1/5 2/5 0 0

1/5 2/5 0 0

NO clonus NO babinski

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