BARBOSA, Leira Ysabelle C.
OMMC Department of Pediatrics
Post-Graduate Intern September 7, 2020
Date of Interview: September 6, 2020; 3:30 PM
Location: Ospital ng Maynila Medical Center
Informant: Mother of the patient
% Reliability: 95%
General Data
The patient is J.R., a 2-year old male, of unknown nationality, religion, and residence. He was
brought for the first time at the Department of Pediatrics of Ospital ng Maynila Medical Center (OMMC)
last September 6, 2020, at around 3:30 in the afternoon.
Chief Complaint
“Shaking all over with eyes rolled back”
History of Present Illness
Prior to onset of the chief complaint, the patient was noted to have colds, with associated
rhinorrhea, and otalgia without ear discharge. No medications or interventions were done to alleviate the
symptoms.
Thirty minutes PTC, the mother observed that the patient was febrile (temperature: 38.5 degrees
Celsius) and crying in her arms when he had sudden-onset rhythmic jerking and twitching of the arms and
legs. It was accompanied by upward rolling of the eyes, excessive salivation, cyanosis, and biting of the
tongue. No associated lip smacking, facial twitching, or loss of urinary/bowel control. The patient was
unresponsive during this episode, which lasted for 2 minutes. He was noted to be drowsy and confused
after the seizure, and took approximately 5-8 minutes to “return back to normal”. This was the first time he
had a seizure and no recurrences were noted afterwards. No interventions were done. The mother then
brought the patient to our institution.
Review of Systems
Constitutional: No weight change
Skin: No rashes, skin pigmentation, hair loss or pruritus
Cardiovascular: No orthopnea or chest pain
Gastrointestinal: No bowel changes, vomiting, melena, hematemesis, hematochezia or jaundice
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Genitourinary: No dysuria, or changes in urine color
Hematopoietic: No pallor, bleeding or easy bruisability
Musculoskeletal: No swelling in bone, joint or muscle; No stiffness or limitation of movement
Personal History
Birth and Maternal History
The patient was born full term to a then __year old G1P0 mother at a local hospital. The mother
had no history of illness, alcohol intake, bleeding nor exposure to infections or radiation during pregnancy.
Number of prenatal consultations were not elicited. He was delivered via spontaneous vaginal delivery,
without complications. He had good cry and activity without meconium staining. Birth weight was 4 kg,
with the length and pediatric aging unrecalled.
Feeding History
Not elicited.
Developmental History
Motor: Turns head from side to side: 1 month, Sits independently: 6 mos., Stands without
support: 12 mos., Walks: 13 mos. At present, able to balance, jump, kick, and throw things.
Language: At present, able to speak in sentences.
Personal/social: At present, able to imitate activities and play peek-a-boo.
According to the mother, he was noted by his previous doctor to be developmentally appropriate
for his age.
Past Illnesses
History of hypersensitivity and childhood illnesses was not elicited. Prior hospitalizations, surgical
operations or accidents were also not mentioned.
Immunization History
The mother claimed that he is compliant with his immunization schedule. No new vaccination in
the last 2 weeks.
Family History
The patient has no siblings. There is no history of seizures in the family. No other heredofamilial
disorders nor pertinent diseases were recalled by the patient’s mother.
Socioeconomic and Environmental History
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The patient is currently residing with his parents. Present address was not mentioned. Their
occupations and source of income were also not elicited. Details of the patient’s living conditions and
environment were not mentioned.
Physical Examination
General Survey
During the interview, the patient appears to be diaphoretic but is well-developed, well-nourished,
and not in cardiorespiratory distress. Patient looked his chronological age of 31 months old.
Vital Signs
The patient’s temperature is 39.5 degrees Celsius. His respiratory rate is _ breaths per minute
and was noted to be regular. His BP is 90/60 and the radial pulse rate is 112 beats per minute. The
patient’s oxygen saturation measured by pulse oximetry is __%.
Anthropometric Data
o Weight = 15 kg
o Height = 94 cm
o BMI = 17 kg/m^2
Growth Indicator Interpretations
Indicator Z score Interpretation
Height-for-age Value is between 0 and +2 SD markers Norma
Weight-for-age Value is between 0 and +2 SD markers Normal
Weight-for-height Value is between 0 and +1 SD markers Normal
BMI- for-age Value is between 0 and +1 SD markers Normal
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Skin and Nails
The skin is brown in color, with no observable cyanosis, jaundice or pallor. There are few
1x1 cm macules and papules, brown and pink in color, located on the anterior chest. Nail beds
are pinkish. Skin turgor, temperature, and texture was not taken.
Head
The head is normocephalic, with no deformities, or masses. The hair is black in color,
smooth, adequate in amount, and is normally distributed. There are no lice, nits, or scaling
observed.
Face
The face is symmetric, non-edematous, and has no lesions nor unusual facies.
Eyes
The eyes are aligned, with non-edematous eyelids that can be adequately closed. The
lacrimal gland is non-palpable. The sclera is white, the palpebral conjunctiva is pink, and the
bulbar conjunctiva is clear. The cornea is clear and has no opacities while the iris appears
normal. Pupillary reflex, visual acuity, visual field testing, assessment of extraocular muscles, and
observation of red-orange reflex were not performed.
Ears
The external ears are symmetrical, with no visible deformities, no tenderness, or swelling.
The ear canal is erythematous with. Tympanic membrane is intact with dilated blood vessels. No
air fluid levels or discharge were noted.
Nose
The nasolabial folds are symmetrical and the septum is midline with no visible
deformities. Nasal mucosa is pink with no visible discharge. Sinuses were not examined.
Mouth and throat
Lips are pinkish and moist with no visible lesions. Oral mucosa and gingiva are pink with
no visible lesions. Uvula is midline. Tongue is pink and symmetrical with no visible lesions.
Pharynx is pink with no visible lesions. Tonsils are not visible (Grade 0).
Neck
No venous engorgement, or neck masses. Trachea is midline.
Thorax and Lungs
The transverse diameter is greater than the anteroposterior diameter. There were no
lesions or gross deformities of the chest and spine. The rhythm and rate of breathing were
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regular. There were no chest retractions, use of accessory muscles or audible breath sounds.
There were no masses or areas of tenderness on the anterior and posterior chest upon palpation.
Chest expansion was symmetric. Anterior and posterior lung fields were resonant upon
percussion. Upon auscultation, bronchovesicular breath sounds were noted. There were no
adventitious breath sounds like crackles, wheezes, rhonchi, friction rub, or stridor. Vocal fremitus
and bronchophony were not performed.
Chest and Heart
The precordium was adynamic. Upon inspection of the chest, there were no scars or
chest deformities; no visible pulsations or bulging observed. There were no palpable heaves or
thrills. The point of maximal impulse (PMI) was not located and measured. The heart rate is at
110 bpm, and was regular in rhythm and rate. S1 was louder than S2 at the apex, while S2 was
louder than S1 at the base. There were no S3 and S4. There were no murmurs on systolic or
diastolic phases heard on all auscultatory points.
Extremities
Both arms and legs were symmetric and non-edematous. There were no lesions or nail
clubbing. The temperature, capillary refill time, and grading of the pulses were not taken.
Abdomen
Abdomen is slightly globular, symmetric, with a centrally located umbilicus. No visible
pulsations, organs, masses, and bulging flanks observed. No scars, striae, or dilated veins. Bowel
sounds were normoactive. No bruits, friction rubs, or venous hum heard on auscultation.
Abdomen was soft and nontender; it was tympanitic on all quadrants. No palpable masses or
lumps.
Cranial Nerve Examination
Not performed.
