ENDORSEMENT
Bimbao, Figueroa, Villanueva
Junior Interns
CLMMRH
Department of Pediatrics
GENERAL DATA
Name: C.D.
Age: 7 months old and 9 days
Sex: Female
Address: Brgy. Culipapa, Hinoba-an, Negros Occidental
Date of Birth: July 7, 2016
Religion: Roman Catholic
Nationality: Filipino
Informant: C.D.S
Relationship to Patient: Mother
Reliability: 90%
CHIEF COMPLAINTS
Difficulty of breathing
Yellowish Discoloration
of the skin
HISTORY OF PRESENT ILLNESS
Patient was born full term via NSVD, small for
gestational age at 2.2 kg. Born at a local district hospital
assisted by an OB-GYNE with no complications.
Patient was born to a G1P1 (1001) 31 year old mother
with regular prenatal check up starting at 5 months
AOG, with no maternal illnesses.
HISTORY OF PRESENT ILLNESS
At 4 months old
Folks noted generalized jaundice, icteric
sclerae, protuberant abdomen and acholic
stools.
Sought consult
Given request for ultrasound, complied.
Ultrasound of Whole Abdomen
FEEDING HISTORY
Exclusive Breastfeeding until 1 month of age, shifted to milk
formula at 1 month to present
PAST PERSONAL HISTORY
GROWTH AND DEVELOPMENTAL HISTORY
Gross Motor Fine Motor Hearing & Social Behavior
Speech
Rolls from front to Stretch both Responds to (+) strangers
back, cannot sit hands and grasp name anxiety
with support object
PAST PERSONAL HISTORY
IMMUNIZATION
BCG 1 dose
DPT 3 doses
HBV 3 doses
OPV 3 doses
PAST MEDICAL HISTORY
No heredofamilial diseases
SOCIOECONOMIC HISTORY
Mother is a housewife
Father is a fisherman
Main source of income: from the fathers job
ENVIRONMENTAL HISTORY
GENERAL SURVEY:
Awake, Spontaneous motor movement
Good cry and suck
PHYSICAL EXAMINATION
PARAMETER PATIENTS RESULTS
Temperature 37 C
SKIN
Generalized Jaundice
HEENT
Normocephalic; No hematoma, abscess or edema; No facial
asymmetry; Icteric sclerae, pinkish conjuntivae, pupils are
equally round and reactive to light and accommodation; No
nasal flaring; No nasal/ear discharges
PHYSICAL EXAMINATION
NECK
Trachea is at midline; No lumps; No cervical
lymphadenopathies
PHYSICAL EXAMINATION
ABDOMEN
Protuberant with girth of 42.5 cm, normoactive bowel sound . Dull
on percussion with areas of tympany. Liver is firm with liver span
of 5cm from the substernal line. (-) tenderness on palpation
INGUINAL REGION
No palpable masses and lymph nodes
GENITALIA
Grossly female genitalia
PHYSICAL EXAMINATION
NERVOUS SYSTEM
MENTAL STATUS EXAMINATION- cannot assess
SENSORY- grasps finger when touched, change in facial
expression when touched.
CEREBELLAR- not assessed
DEEP TENDON REFLEXES- not assessed
Cranial nerves
I: not assessed
II: regards face
II,III: blinks to light, (+) direct and consensual light reflex
III, IV, VI: tracts object
V: able to bite down
VII: cries with no facial asymmetry
VIII: turns to sound
IX, X: good suck and swallows
XI: not assessed
XII: symmetrical tongue protrusion when nose is pinched
Laboratories
Exam name Result Normal values
Total Bilirubin 7.36 mg/dL 0.1-1.0 mg/dL
Indirect Bilirubin 2.64 mg/dL 0.1-0.6 mg/dL
Direct Bilirubin 4.72 mg/dL 0-0.4 mg/dL
Alkaline Phosphatase 878 U/L 39-117 U/L
SGPT/ALT 244 U/L 3-31 U/L
CBC Result Normal Values
Hematocrit 0.14 0.27-0.43L/L
Hemoglobin 44 85-145 g/L
RBC count 2.14 4.5-5.5 10^12/L
WBC count 13.9 4.5-11 10^9/L
segmenters 50 50-70%
lymphocytes 39 25-35%
monocytes 6 0-15%
eosinophil 5 1-5%
Platelet 162 84-478 10^12/L
Chest X-ray
AP
Lateral