IV.

PEARSON ASSESSMENT

April 10, 2007 Tuesday April 10, 2007

Wednesday
John Michael Bitan 4y/o male child from 161 Patient is conscious and

P
kaybagal Central, Tagaytay City, Roman Catholic. coherent.
He is living with his parents Ma. Theresa & Rowel
Bitan. Still irritable. Speaks a 1
word at a time to a
General appearance: doctor who visited him
He is weak in appearance. Unable to properly and talked with him.
communicate with people because he has difficulty
in speech. Irritable. Muscle atrophy noted on lower Weakness and muscular
extremities. atrophy on lower
extremities is noted, ®
Hx of Past illness: arm is also paralyze
Last June 2006 he experienced vomiting and seeks
for medical consultations & he was diagnosed to
have a tumor in his brain. He undergone
craniotomy at NCH and was diagnosed with
Primitive Neuroectodermal Tumor. He was
discharge on November 20, 2006. his father’s side
has a history of having cancer and he has no history
of having diseases.

Hx of present illness:
1 week PTA patient was noted to have body
weakness due to vomiting. A day PTA patient is
still weak and had decrease appetite. Patient was
brought to NCH for consultation and further
treatment. CT scan revealed that tumor had re
occurred and disseminated much of his brain. The
condition is getting worse day by day.

Neonatal condition and feeding:

He was born via NSD attended by a manghihilot,
he was breast fed until 2y/o and since then he was
fed with formula milk(nido fortified). He began to
eat solid foods @ 1y/o.
Growth & development:
Sat alone @ 6months
Stood alone @ 9months
Walked @ 1yr 3month
Talked @ 1y/o
He is currently a nursery student.

Immunization:
BCG: given
DPT: completed 3 doses
OPV: completed 3 doses
Hepa B: completed 3 doses
Measles:given
S>
“mga march 30 noong magsimulang di niya
 maigalaw ang kanyang kanang bahagi ng kanayang
katawan niya” as verbalized by the mother.
“ lagi siyang irritable mula noong naoperahan siya
sa ulo” as verbalized by the mother.
“ako nga lang ang kinakausap niya ng matino.
Minsan ayaw din niya akong kausapin” added by
the mother

Eliminates through diaper, an average of 2 per day. Eliminates through

E
Usual bowel pattern. Sweats moderately. diaper, an average of 2
per day. Usual bowel
pattern. Sweats
moderately.

Sleeps fairly Sleeps fairly.

R
Activity: mostly lying on bed and sitting on Activity: mostly lying on
wheelchair. bed and sitting on
Cannot move w/o assistance thus having difficulty wheelchair. Weakness
performing ADL. and muscular atrophy on
lower extremities is
noted, r arm is also
paralyze

He has difficulty in

S
He has difficulty in speech speech.
Weakness at booth lower extremities and R arm is
noted Weakness at booth lower
extremities and R arm is
Seat strap on wheelchair is put on and side rails are noted.
raised for safety.
Seat strap on wheelchair
facial edema noted is put on and side rails
are raised for safety
Weak in appearance

No known allergies to any foods

Medications:
Gentamicin 75mg IV OD
Dexamethasone 5mg IV q 6
With initial V/S as follows: With initial V/S as

O
BT 36.8C follows:
PR: 100bpm BT 37.1C
RR: 18cpm PR: 98bpm
c HL @ R forearm intact RR: 18cpm
no DOB c HL @ R forearm intact
Hgb 14.6g/dl not in distress
Hct 44%
WBC 11.2
Neutrophils 0.92
Lymphocytes 0.08
Platelet count: 295
 Diet appropriate for age Diet appropriate for age

N
Good appetite. Eats 1 cup of rice and bacon with Good appetite.
egg.

V. Diagnostic Procedures

A. Ideal
CBC(Complete Blood Count) – A complete blood count is a lab test performed on sample
of your blood, includes a determination of your hematocrit, the percentage of the blood that
consist RBC. The CBC also measures the amount of Hgb in your blood.

WBC (5,000-10,000/mm3) – These are cells that usually fight infection. If this count is
elevated it may indicate presence of infection or steroid treatment. If the count is low, it is
usually from medications, infections, autoimmune diseases, or blood disease among many
other causes.

Neutrophils (55-70%) – may be elevated with bacterial infections, burns, stress, or

inflammation,. A decrease may be caused by radiation, certain drugs, vit. B12 deficiency or
systemic lupus erythematosus.

Eusinophils(1-4%) – may be elevated due to allergies, parasitic infections, autoimmune

disease or adrenal insufficiency. A low eosinophil count could be caused by Cushing’s
syndrome, certain drugs, or stress.

Lymphocytes (20-40%) – May be elevated in viral infections, immune diseases, and sime
leukemia. Low numbers may be seen in prolonged, severe illness, during chemotherapy, and
when high levels of steroids are present.