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Identifying Data Chief Complaint History of Present Illness

1) A 4-year-old male patient presented with a 5-day history of cough, fever, headache, and decreased appetite. He previously had pneumonia and is allergic to seafood. 2) On examination, he had nasal discharge, ear pain, and difficulty breathing when lying down. His father has hypertension and his mother has asthma. 3) He lives in a crowded neighborhood and was previously exposed to a neighbor with tuberculosis. A review of systems was notable for weight loss, ear discharge, and headache.

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28 views

Identifying Data Chief Complaint History of Present Illness

1) A 4-year-old male patient presented with a 5-day history of cough, fever, headache, and decreased appetite. He previously had pneumonia and is allergic to seafood. 2) On examination, he had nasal discharge, ear pain, and difficulty breathing when lying down. His father has hypertension and his mother has asthma. 3) He lives in a crowded neighborhood and was previously exposed to a neighbor with tuberculosis. A review of systems was notable for weight loss, ear discharge, and headache.

Uploaded by

mhegan07
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Adiova, Agripa, Arrogante, Cariño, Dioquino, Esplana, Gobres, Hermoso, Lopez, Maceres,

Oarde, Peñol, Quitangon, Solomon, Yu (BUCM Sept 1-30)


Setting: BRTTH Tent 1, 5:00PM, September 1, 2020
Source: Mother
Reliability: 85%

Identifying data​: CG, 4 years old, male, Albay


Chief complaint​: Cough

History of Present Illness​:


Five days prior to consult, the patient started coughing with ​halak which happens during
bedtime and is aggravated by hot weather. His mother gave him Ambroxol 5mL TID, which
provided no relief. Patient’s appetite was also reported to have decreased. The mother revealed
that they had a travel history from Quezon City 3 weeks PTC but claimed that they followed
quarantine protocols. No other associated symptoms were noted. No consultations were sought.
Three days prior to consult, the cough persisted and the patient developed colds with
yellow-green nasal discharge. The mother noticed foul-smelling discharge from the right ear
while giving the patient a bath and it was associated with irritability. Difficulty of breathing
exhibited by nasal flaring and chest retractions when the patient is lying supine was also noted.
No other symptoms were noted. Still, no consultations were sought.
Few hours PTC, patient developed fever with a temperature of 38°C and associated with
headache. He was given paracetamol 5 mL every 4 hours which provided temporary relief.
Persistence of symptoms prompted consult to this institution.

Past medical history​:


Previous hospitalization: Admitted due to pneumonia for 1 week (2018) at East Avenue Medical
Center
Allergies - seafood, relieved by Cetirizine

Family history
(+) Asthma - Mother
(+) HTN - Father
(-) TB

Personal and social history:


Patient is the youngest among 3 children. He is taken cared of by his grandmother most of the
time. Both patient and guardian avoided going outside since it was advised to do so. Members
of the household observe minimum health protocols at work and at home.
Patient attended daycare. He was active at the center and got along well with his friends and
teachers.
Patient lives in a neighborhood with houses built very close to each other. Patient sleeps in one
room together with his siblings but was isolated once he developed symptoms.

1
Adiova, Agripa, Arrogante, Cariño, Dioquino, Esplana, Gobres, Hermoso, Lopez, Maceres,
Oarde, Peñol, Quitangon, Solomon, Yu (BUCM Sept 1-30)
Review of systems:
General: (+) weight loss (+) body weakness
Skin: (-) cyanosis (-) jaundice (-) pallor (-) redness (-) hair loss (-) alopecia
HEENT:
Head: (+) headache (-) migraine (-) vertigo
Neck: (-) lumps (-) swelling (-) lesions
Eyes: (-) visual loss (-) diplopia (-) color blindness (-) pain (-) redness (-) blurring
(-) discharge (-) abnormal tearing
Ears: (-) deafness (-) tinnitus (+) discharge, AD​ ​(+) pain
Nose: (-) epistaxis
Throat: (-) hoarseness (-) sore throat
Mouth: (-) sores (-) gum bleeding (-) swelling
Cardiovascular: (-) palpitations (-) chest pain
Gastrointestinal: (-) dysphagia (-) nausea (-) vomiting (-) pain (-) hematemesis (-) melena
(-) diarrhea (-) constipation
Genito/Urinary: (-) change in urinary color (-) polyuria (-) oliguria (-) nocturia (-) dysuria
(-) hematuria (-) incontinence (-) discharges
Musculoskeletal: (-) joint pain (-) muscle pain (-) edema (-) paralysis (-) paresthesia
Neurologic: (-) change in mood (-) change in speech (-) change in attention
(-) change in behavior
Hematologic: not elicited
Endocrine: not elicited

Environmental history:
(+) Smoking, father
(+) Pet dog
(+) TB patient, next-door neighbor

Birth and maternal history:


Mother had no history of illness, alcohol intake, nor bleeding during pregnancy.
She had regular consults with an OB-GYN and was well-nourished throughout the pregnancy.

Growth and developmental history:


Patient can sit without support at 7 - 8 months

Nutritional (Feeding) history:


Patient was purely breastfed until 6 months. At 6 months, he started consuming semi-solid food
such as cerelac and fruits. At 12 months, he started eating soft food such as fish. Presently, his
diet consists mostly of processed food such as hotdog, tocino, and egg. He does not eat
vegetables and fruits. He is also taking multivitamins regularly.

Immunization history:
(+) MMR (+) BCG (+) OPV (+) Pentavalent Vaccine (+) Hepatitis B

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