Pediatric patient-05

History
Date & Time of H&P: 04/07/2024, 12:30

Identification:

This is Baby Mastewal a 31-days-old male patient who lives in Addis Ababa, born from a 25 year old
mother who is a housewife and with an educational level of elementary school and a father of 29 year old
with an educational level of elementary school, as well and works as a labourer. He arrived at ZMH in an
ambulance on June 27, 2024 based on a referral from a local health center. The history was obtained from
both parents, who are both considered to be reliable historians. And, he has no previous admission.

Chief complaint: Abdominal swelling of 7-hours duration

History of Present Illness:

The parents stated that their baby appeared to be healthy since his discharge from ZMH where he was
delivered up until Thursday, the day of his admission or the 24th day after delivery, where they noticed an
abdominal swelling at around 5:00 in the afternoon after an episode of breastfeeding which was sudden,
constant, non-positional & localized only to the abdomen, non-pitting, with no associated tenderness
when touched over the abdomen & not aggravated or relieved by any situation. There was also grunting
& a mildly elevated body temperature which was generalized, sustained, gradually increasing in intensity
& accompanying the abdominal swelling. After exhibiting these signs the patient was taken to a local
health center at around 12:00, in which case they did a blood test & referred him to ZMH on that very
day. Upon his admission at ZMH he stayed for 1 week in the NICU & then was admitted to the pediatric
ward on Thursday July 04.

→ Perinatal history

Baby Mastewal was born at 42 weeks gestation via induced vaginal delivery to a 25 year old mother who
is G2P2 & whose first prenatal visit was in the beginning of her second trimester & continued till birth.
The mother claims to have been in a healthy state throughout her pregnancy except for a case of elevated
blood pressure in the last 2 or 3 weeks of pregnancy & was not on any medication except for the
supplements she was taking. She has a previous pregnancy which she gave birth to a healthy female via
vaginal delivery who is currently 6 years of age. There were no complications both during the pregnancy
or delivery which was at ZMH. And, although the mother doesn’t understand or recall the APGAR score
she stated the baby was of pinkish color, weighed 3kg & cried immediately after delivery. He’s currently
on exclusive breastfeeding from bilateral breast interchanging after finishing one to the other for about 10
times a day each time in the range of 5 to 10 minutes & although not always sleeps 1 to 2 hours or passes
stool after being breastfed & changes diaper at least 3 times a day. The patient had sunlight exposure 3 to
4 times a week starting from the 14th day of birth for 20 to 30 minutes in the morning which is full, direct
& without ointment. In addition, he’s vaccinated for his age according to the EPI.
→ Developmental history

It was stated the baby hasn’t yet achieved any of the developmental milestones.

Past Medical history:

No past medical history or hospital admissions, excluding the time of delivery, to date. Parents deny any
accidents, injuries or illnesses.

Family history:

The parents claim there’s no family history of communicable (TB, COPD, or Pneumonia), familial (DM,
HTN, Epilepsy, or genetic disorders) or sexually transmitted disease (Chlamydia, Herpes, HIV).

Personal & Social history:

Patient lives with his married parents along with his older sibling who is a 6 year old girl. The family of 4
lives in a small rental house that’s in poor condition which has a single room along with a single window
& door. The kitchen isn’t separated from the living quarters & they use coal as a heat source for cooking.
And, they claim to have an adequate water supply via a water pump.

Review of Systems:

HEENT — No headache, or head injury. No signs of ear pain, deafness, discharge, vertigo, or
tinnitus. No signs of disturbed vision, lacrimation, pain, itching, or photophobia. No signs of
nasal congestion, discharge, or bleed. No signs of sore throat, bleeding gum, or hoarseness.
Lymphoglandular system — No signs of mass on the neck or chest, heat or cold intolerance,
swollen salivary glands, or swollen testes.
Respiratory system — No cough, fast breathing, chest pain, or audible breath sounds are present.
Cardiovascular system — Swollen hands or ankles, chest pain, palpitations, waking or positional
breathlessness, bluish tint of the fingers or lips, or loss of consciousness are absent.
Gastrointestinal system — Besides the abdominal distension & decreased appetite (in his stay at
ZMH NICU), nausea, vomiting, constipation, diarrhea, excessive burping or flatulence, rectal
bleeding, abdominal pain, heart burn, or discomfort during swallowing is absent.
Genitourinary system — No signs of flank pain, urgency, hesitancy, or incontinence.
Neurological system — Altered mental status, abnormal body movement, memory difficulty,
communication problem, or paralysis are absent.
Musculoskeletal system — No joint or bone pain, back pain, swelling or limping.
Integumentary system — No skin dryness, ulcer, rash, change in finger nails, hair loss, or itching.

Otherwise, the patient has no history of abnormal (red or dark) color of stool. — Necrotizing
Entercolitis (NEC)
He has no vomiting or failure to pass stools. — Gastrointestinalobstruction
He has no history cough, fast or labored breathing, or audible breath sounds. — Pneumonia or
Bronchiolitis
He has no apparent painful urination, blood tinged urine, or vomiting. — UTI
 He has no swelling of the feet or area around the eye. — RHF or
There’s no sign of floppy or stiff muscle, vomiting, sudden jerking movements, unusual or
excessive crying. — Meningitis
There was no maternal infection during the course of pregnancy or at time of delivery. —
Chorioamnionitis
There was a post-term delivery. — Prolonged exposure to intrauterine environment, Meconium
aspiration syndrome, Labor complications & Compromised immune functionns
The baby lives in poor living conditions.

Physical Examination
General appearance:

Acutely sick looking

Well nourished
No skin color change
Respiratory distress is absent
Tired & Agitated

Vital signs:

Temperature: 38 °C, Axillary — Hyperthermia

Pulse rate: 173 regular & full volume, from the right-hand — Normal
Respiratory rate: 38 — Normal
Blood pressure: -
SpO2: 95% on room air

Anthropometry:

Length: 54cm
Height: -
H/L: -
Weight: 4.4kg
Head circumference: 41cm
MUAC: 12.5cm
W/H/L2: -
Height/Length for age: on 0 — Normal
Weight for age: between 0 & 2 — Normal
Head circumference for age: on 3 — Macrocephaly
Weight for length: between 0 & -1 — Normal
BMI for age: -

HEENT:

 The shape of the head is oval, with a dark hair of normal thickness that is normally distributed &
with no sign of easy pluckability, or flag sign. Both the anterior & posterior fontanelles aren’t
 closed & are sized 2x2cm & 2x1cm, respectively & the suture lines aren’t fused, as well. In
addition, there are no visible scars or skin lesions, frontal bossing, Craniotabes, or Uraemic frost.
 The eyes are positioned symmetrically at a normal distance apart with no signs of ptosis,
Xanthelasma, discharge, eyelid retraction, or periorbital edema, the conjunctiva maintains its
normal pallor & the color of the sclera appears to be clear white with no sign Perilimbal injection,
band keratopathy, Bitot spots, or jaundice. A normal movement of the eye is present & the pupil
appears to be clear dark, circular, around 4mm in size with room light, with no sign of opacity, or
Coloboma. There’s also no sign of corneal arcus, or Kayser-Fleischer rings.
 The ears appear to be of normal size & symmetry, with no skin tag, discharge, or tenderness.
 The nose also appears to be of normal shape & is patent with closed mouth. In addition, there’s
no sign of discharge, epistaxis, nasal septum defect, occlusion by any kind of mass, or tenderness
on the maxillary & frontal sinuses.
 The color of the lip is pinkish & there’s no cleft lip or palate, angular stomatitis, or protrusion of
tongue. In addition, the lips are dry & but not cracked. Upon examination of the mouth there’re
no Aphtous ulcers, oral thrush, papillary atrophy, bleeding or hypertrophied gums, high-arched
palate, sub-lingual cyst, dryness, uremic fetor, or tooth caries. In addition, the tonsils appear to be
intact & symmetrical.

Lymphoglandular System:

 On general observation, there’s no sign of bleeding or bruising, abdominal distension, paleness,

or cachexia.
 On inspection & palpation of the cervical, axillary, epitrochlear & inguinal lymph nodes there’s
no sign of mass, tenderness, indurations, color change, or increased warmth.
 On palpation of the thyroid & parotid glands there was also no sign of mass, tenderness, skin
changes, or increased temperature.

Respiratory System:

 On general observation, there’s no sign of respiratory distress, audible breath sounds, or any form
of cyanosis. The trachea appears to be in the mid-line.
 On inspection of the hands peripheral cyanosis & clubbing are absent. On inspection of the eyes
the conjunctiva doesn’t appear to be pale. There’s no central cyanosis on inspection of the mouth,
as well. On inspection of both the anterior & posterior chest wall there’s no scar, asymmetry, or
deformity.
 On palpation, the position of the trachea is in the mid-line, there’s no mass or tenderness over the
chest wall, tactile fremitus appears to be symmetric & normal and also the chest expansion is
symmetric & normal.
 On percussion, the chest appears to be symmetrically resonant.
 On auscultation, there’s a good air entry and the vesicular, broncho-vesicular & bronchial breath
sounds can be heard, with no added sounds.

Cardiovascular System:

 On general observation, there’s no shortness of breath, or as previously stated paleness or

cyanosis.
  On inspection of the hands there’s no splinter hemorrhages, Janeway lesions, or Osler’s nodes.
Other inspection findings of the hands & face have already been or will be reported. The Jugular
vein isn’t visible, there’s no bulging or deformity over the pericardial area & the pericardium
appears to be quiet.
 On palpation capillary refill time of the hands appears to be intact, there’s no radio-radial delay,
the carotid artery beats at a regular rhythm & at full volume, the apical impulse is on the 5 th
intercostal space & is not diffused & there’s no finding of heaves or thrills over any of the valves.
 On auscultation both S1 & S2 can clearly be heard, with no murmurs, S3, or S4 sounds.

Abdominal Examination:

 On general observation, there’s no sign of confusion, jaundice, paleness, or hyperpigmentation.

 On inspection of the hands there’s no palmar erythema, Dupuytren’s contracture, finger clubbing,
Koilonychia, leukonychia, or Asterixis. Upon inspection of the arms there’s no bruising or
excoriations. Inspection of the eyes & tongue has already been mentioned in the HEENT section.
There’s no spider naevi upon inspection of the anterior chest wall. On inspection of the abdomen,
the abdomen moves with respiration & the umbilicus is inverted & circular. And, there’s no scar,
abdominal distension, peristaltic movements, hernia, striae, caput medusae, Cullen’s sign or
Grey-Turner’s sign.
 On auscultation of the abdomen normal bowel sound could be heard at a normal rate. And, aortic
or renal bruits & hepatic or splenic friction rub are also absent.
 On palpation of the Virchow’s nodes there’s no mass or tenderness, they couldn’t be palpated, as
well. On superficial palpation of the abdomen, there’s no sign of mass or tenderness & voluntary
or involuntary guarding. On deep palpation, there’s no sign of mass or tenderness, as well. And,
there’s no rebound tenderness. The liver & spleen couldn’t be palpated & the kidneys couldn’t be
balloted.
 On percussion the abdomen appears to be tympanic allover, thus not necessitating the fluid thrill
& shifting dullness examinations. And, the TVLS appears to be 7cm.
 DRE wasn’t performed.

Genitourinary System:

 There’s a normal male genitalia, that’s circumcised. And, there’s no lump or tenderness over the
inguinal region.

Musculoskeletal System:

 On inspection, palpation & passive movement of the shoulder, elbow, wrist, joints in the hands,
hip, knee, ankle & joints in the foot appear to be intact & working with good condition.

Integumentary System:

 Upon inspection of the skin there’re no rashes or lesions, decreased thickness, or dryness. On
inspection & palpation of the nails on both the hands & foot there’s no deformity or abnormal
findings either. Inspection & palpation of the hair has already been reported over the HEENT
section, which has no abnormal findings, as well.
Neurological Examination:

 Mental-status examination
The Glasgow isn’t reported due to the age of the patient.
 Cranial nerve examination
CN III: Oculomotor nerve examination shows no ptosis & intact eye movements & pupillary
reflex to light
CN V: Trigeminal nerve examination shows intact corneal reflex.
CN VII: Facial nerve examination wasn’t done fully, but facial movements are present.
→ The rest of the cranial nerves weren’t examined due to inconvenience or uncooperativeness of the
patient.
 Examination of motor function
Muscles appear to be a symmetrical & of equal bulk, with no tremor of fasciculations.
Plantar reflex is present. However, abdominal & cremasteric reflexes appear to be absent.
Anal reflex wasn’t tested.
→ Examination of sensory function, coordination, station & gait were also not performed.
 Other tests
The patient appears to be negative for nuchal rigidity, Brudzinski’s & Kernig’s sign.
The Lasegue sign is also negative.

Differential Diagnosis
1. Neonatal sepsis:
2. Meningitis:
3. Lymphatic obstruction:
4. Congenital infections: infections like CMV, Syphilis, Toxoplasmosis & Rubella can present
with various systemic symptoms.
5. Systemic inflammatory response syndrome
6. Viral infections: HSV, Enterovirus, or RSV.

Investigations
Laboratory tests:
CBC to check for infections
C-Reactive protein levels to check if there’s any inflammation
Lumbar puncture to obtain CSF
Imaging:
Chest X-ray
Culture:
Blood culture
Urine culture