General Data

• P.A.• 4y/o, F• Quezon City• Roman Catholic/Filipino• Date of admission: 4/29/10• Informant: mother• Reliability: good

Chief complaint

FACIAL EDEMA

History of Present Illness

- (+) fever (undocumented)- (+) sorethroat- (+) rashes (red, pruritic patches?)- no cough and colds- Consult at local clinic and diagnosed

with tonsillopharyngitis- Given Co-amoxiclav (unrecalled

dosage) until lysis of fever (4 days)

18 days PTA

History of Present Illness

- Facial and periorbital edema- Abdominal enlargement- Difficulty of breathing- Tea-colored urine- ↓ urine output- no edema of extremities- No medications taken- No consultation done

3 days PTA

History of Present Illness

- Consult at a local clinic- Urinalysis, BUN, Creatinine, ESR

- Persistence of symptoms

2 days PTA

Admission

1 day PTA

Review of Systems• General: (-) weight loss, (-) loss of appetite• Cutaneous: (-) pigmentation, (-) hair loss, (-)

pruritus.• HEENT: (+) headache, (-) visual difficulties, (-)

lacrimation, (-) aural discharge, (-) epistaxis, (-) toothache.

• Gastrointestinal: (-) vomiting, (-) diarrhea, (-) constipation, (+) passage of worms, (+) abdominal pain, (-) jaundice, (-) food intolerance.

• Genitourinary: urine yellow in color, (-) burning sensation, (-) discharge

Review of Systems

• Endocrine: (-) palpitation, (-) cold or heat intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia.

• Nervous/Behavioral: (-) tremors, (-) convulsions, (-) weakness or paralysis, (-) mental deterioration, (-) mood changes, (-) hallucinations.

• Musculoskeletal: (-) swelling of bones/joints, (-) stiffness, (-) limping.

• Hematology: (-) pallor, (-) bleeding manifestations, (-) easy bruisability.

Feeding History

• Picky eater, dislikes vegetables• ACI• 24 hour food recall– Breakfast: 1 cup soup, 1 glass milk– Lunch: ½ cup rice, 1 pc chicken breast– Dinner: ½ cup rice, 1 pc chicken breast, mango– Snack: 1 cup noodles with egg

Personal History

Developmental history– hops on one foot– Copies a drawing of a cross and circle– Counts to ten– Plays cooperatively– Goes to the toilet alone

Past Illnesses

• (+) bronchopneumonia (2006)• (+) mumps (unrecalled date)• (-) surgeries or blood transfusions• (-) known allergies • (-) asthma

Immunization History

• BCG• Hep B x 3 doses• DTP x 3 doses• OPV x 3 doses• Measles• BOOSTER DOSE??

At a local health center in Quezon City

Family History

• (+) HPN – father• (-) Renal disease• (-) DM• (-) PTB• (-) Asthma• (-) CA

Family History

Name Age Occupation Educational attainment

Health

Agnes Aguba (mother)

29 Vegetable stand owner

HS graduate Healthy

Gerald Alperto (father)

30 Tricycle driver 3rd yr college Healthy

Wendell Alperto (sibling)

1 yr 4 mos. / Male

-- -- Healthy

Socioeconomic and Environmental History

• Lives with parents and younger sibling in a 1-floor, cemented apartment like complex.

• Well-lit but not well-ventilated (no windows, 1 door)

• 2x/week garbage collection with no segregation• There are no factories nearby, but there is

exposure to vehicular exhaust • Purified drinking water • No pets

PE on Admission• General Description: Patient is awake, coherent, ambulatory, not in

cardiorespiratory distress, well-nourished, and well-hydrated.• Vital Signs: pulse rate 120 beats/min; respiratory rate 36 cycles/min;

temperature 36.5° C; blood pressure 110/70 mm Hg.• Anthropometric Measurements: wt 17 kg (z score below 0), ht 104 cm (z

score below 0), AC: 52.5cm.• Skin: warm and moist, (-) jaundice, (-) edema, (-) loss of tissue turgor.• Head, Eyes, Ears, Nose: (-) swelling, (-) discharge, tympanic membrane intact,

pink, flat, cone of light present, (-) effusion; nasal septum midline, (-) sinus tenderness, (+) facial edema, (+) impacted cerumen.

• Mouth and Throat: moist buccal mucosa, pink lips, (-) dryness, (-) gum bleeding; tongue pink, (-) dryness, non -hyperemic posterior pharyngeal area, grade 3 tonsillar enlargement, (-) exudates.

• Neck: supple neck, (-) palpable cervical lymph nodes.

PE on Admission• Lungs: symmetrical chest expansions, normal vocal fremiti, lung fields

resonant on percussion, decrease breath sounds on anterior chest, fine crackles on the right base of lung, and occasional wheezes.

• Heart: dynamic precordium, (-) thrills, (-) heaves, apex beat 4th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, S2 splits on inspiration, (-) murmurs,

• Abdomen: globular, soft, nontender (-) prominent vessels, (-) striae, (-) pulsations, (-) paradoxic movements with respect to respiration, normoactive bowel sounds (10/min), (-) splenomegaly, (+) costovertebral angle tenderness, (+) fluid wave, (+) shifting dullness, (+) umbilical hernia.

• Extremities: (-) pain, (-) swelling, (-) clubbing.• Spine: (-) scoliosis, (-) tenderness.

Neurologic Examination

• Conscious, coherent, follows commands, GCS15• Cranial nerves intact: Pupil size 2-3 mm equally reactive

to light; no ptosis (OU) intact EOM movements, can move face and shrug shoulders side by side.

• No abnormal movements, normal gait• MMT 5/5 on all extremity, DTR (++) on all extremities• No sensory deficit• No involuntary movement, no spasticity, no atrophy• No nuchal rigidity, no Babinski, no Kernig’s, no Brudzinski

Salient Features

• 4 year old female• Chief complaint of facial edema• Abdominal enlargement• Tea-colored urine• ↓ urine output • Fluid wave• Shifting dullness• 2 ½ week history of tonsillopharyngitis