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1、 By Group3PengSijing Stone LiXiaojing Cathy MiaoChunmei Mango NieFengyan Zara CASEPRESENTATIONPEDIATIRCWARD CONTENTS History PhysicalExamination Introduction LaboratoryResult MIMSMedication NursingCarePlan NeurologicExamination Introduction GENERALDATA p m e 13yearsold female Filipino Christian born
2、onMarch23 2004inManilacurrentlyresidingin270KalayaanB St BatasanHillsQuezonCity admittedforthefirsttimeatFEU NRMFMedicalCenteronMarch3 2018 CHIEFCOMPLAINT Vomiting History HISTORYOFPRESENTILLNESS Fourhourspriortoadmission whileswimminginthepool acontainerofmuriaticacidwasnotedtobeaccidentallyspilled
3、inthepool theamountwasunknowntotheinformant Whilehercousinmovedoutofthepool shesubmergedherselfforafewsecondsuntilshewaspulledoutofthepoolbyheruncle Sheaccidentallyingestedapproximately1cupofpoolwater Shethenexperiencedizziness sorethroat chestpain difficultyofbreathingandbodyweakness Shethenwashedh
4、erselfintheshower Thereafter sheexperienced2episodesofnon projectile non bilous non bloodyvomitofpreviouslyingestedfoodaboutcupperbout Shewasthenbroughttoanearbyhospitalandwashookedtooxygenvianasalcannula Theywereadvisedtotransferhospitalsduetolackofapediatric History HISTORYOFPRESENTILLNESS Fewhour
5、spriortoadmission uponarrivaltotheEmergencyDepartment shehad1cpisodeofnon projectile non bilous non bloodyvomitingofpreviouslyingestedfoodabout1 2cup Stillwithsorethroat chestpain difficultyofbreathingandbodyweakness Nodizzinessnoted Onphysicalexamination shehadsymmetricalchestexpansion withintercos
6、tal subcostalandsupraclavicularretractions cracklesallover wheezesalloverandtightairentry Shehadepisodesofdesaturationwithoxygensaturationof80 90 Completebloodcountwithplateletcountwasdonewhichrevealedleukocytosiswithneutrophilicpredominance BUN Creatinine andElectrolytesweredonewhichrevealednormalr
7、esults Electrolytesshowednormalresults Arterialbloodgasshowedfullycompensatedmetabolicacidosis Shewasadvisedadmission henceadmitted History PASTMEDICALHISTORY Patienthadtheusualchildhoodillnesssuchasmeasles varicella 2011 PatienthadthehistoryofPrimaryPulmonaryTuberculosis 2011 6monthstreatment Compe
8、tedtreatmentin2013 Nohistoryofseizure bronchialasthma dengue allergiestofoodanddrugs historyofsurgeryorblood History FAMILYHISTORY Fatheris37yearsold Highschoolundergraduate Worksasapainter apparentlywellMotheris39yearsold Highschoolgraduate Worksasanailtechnician apparentlywellGrandmotherhasHyperte
9、nsionandinmaintenanceofNorvasc5mgandcompliantNootherheredo familialdiseasessuchasdiabetesmellitus kidneydisease liverdiseaseandpsychiatricillnesses History IMMUNIZATIONHISTORY History NUTRITIONALHISTORY Thepatientwasexclusivelybreastfeduntil6thmonthofage ShewasintroducedtocomplimentaryfeedingwithCer
10、elacandGerberonher6thmonthandricewithviandwasgivenat1yearold Now sheconsumes4cupsofricewithviandthreetimesdaywithsnacksinbetween History HEADSSIRST Homelife patientsharesabedroomandbedwithherauntandgrandmotherEducation sheisan8thgradestudentwithaveragegradesandisapartofthebadmintonclubAbuse nohistor
11、yofabuseDrugs withhistoryofalcoholintake 2cupsofunrecalledalcoholmixture nohistoryofprohibiteddrugintake History HEADSSIRST Family nuclearfamily nohistoryofalcoholnordrugabuseFriends hasdifferentgroupsoffriendsineverysocialsettingbutiscarefulinwhoshehangsoutwithImage seesherselfasfat dressesupliketh
12、e hypebeast cultureSafety playsvolleyballonthestreets noprotectivegear History HEADSSIRST Recreation shelikestoplaysportsandhangsoutwithherfriends sheisveryaciveonvarioussocialnetworkingsitesSpirituality sheisaBornAgainChristianwhogoestochurchonmostSundaysThreatsandViolence shehad1historyofselfharmw
13、henshewas11yearsoldwhenshecutherforearmwithacutterinschool nohistoryofrunningaway crueltytoanimals fightingnorstealing PERSONALANDSOCIALHISTORY History Thepatientliveswithhisparentsandsiblingsina1 bedroom2storyhouse well litandwellventilatedwith1window Themotheristheprimaryfinancialprovider Watersou
14、rceisfromMayniladanddrinkingwaterisfromadeepwell Garbageiscollectedtwiceaweek Hesleepsforabout10hoursaday History OBSTETRICANDGYNECOLOGICHISTORY Patienthadhermenarcheat12yearsold lastingfor5days consuming3padsperday moderatelysoaked withassociateddysmenorrhea Subsequentmenseswereregularwithintervalo
15、f28 30days lastingfor5days consuming3padsperday moderatelysoaked withassociateddysmenorrhea PhysicalExamination GeneralSurvey conscious coherent inrespiratorydistresswiththefollowingvitalsignsBP 120 80mmhgCR 100bpmRR 36cpmTemp 36 8CO2Sat 87 Wt 37 7kgHt 155cmBMI 15 71kg m2IBW 47 63kgz score nostuntin
16、gnowastingHEENT pinkpalpebralconjunctiva whitesclera intacttympanicmembrane pinkandboggyturbinates moistlips moistbuccalmucosa pinkpharyngealwallNECK suppleneck nopalpablelymphnodes non tender PhysicalExamination CHEST LUNGS symmetricalchestexpansion withintercostal subcostal supraclavicularretractionscracklesonalllungfields wheezesallover tightairentry HEART Adynamicprecordium normalrate regularrhythm nomurmurABDOMEN flat soft nontender normoactivebowelsounds non tenderEXTREMITIES nogrossdeform
