This is the case of AMN, a 3 year old single male child, who was admitted to . He is a Roman Catholic and a Filipino who was born at CHR V Langkaan II Phase II, Dasmariñas Cavite and currently residing at B36 L18 CHR V Phase II, Dasmariñas Cavite. He has two other siblings, Alvin and Jeng-jeng who stayed with him at the hospital with his grandmother. The person to be contacted with regards to his condition is his mother, Evangeline Nietes who lives with him. His current physician is Dra. Castro. His father and grandmother was the informant with 75% reliability when asked about the general data and health history of Aldrin. The patient was admitted with the chief complaint of body weakness and eye crossing. Based from the interview, 2 months prior to confinement, Aldrin fell during play from about 4-5 feet of landing and hit his head at the fronto parietal area to the ground. No vomiting was noted nor loss of consciousness. However, he was noted to have an on and off fever but undocumented and no consultation was done. A month prior to admission he still has an on and off fever and was noted to have an increase in sleeping time and weaker for he can’t hold the milk bottle anymore and can’t stand properly nor walk alone and still no consultation was done. Until 2 weeks prior to confinement, still with on and off fever, he suddenly had an upward rolling of the eyeballs with drooling of saliva and stiffening of extremities which lasted for about 2 minutes. He was then rushed to General Emilio Aguinaldo Memorial Hospital, before the admittance to San Juan de Dios Hospital. During admission the patient had recurrence of seizure with the same characteristics. He was treated with Pen. G and Chloramphenicol. Complete Blood Count revealed leukocytosis, increase of segment matter and platelet count. Electrolytes were also requested which revealed normal results. Chest X-ray was done to consider PTB. Cranial CT Scan was requested according to the informant, however, it was not done. He was sent home per request with the impression of TB meningitis then after 7 days was admitted to San Juan de Dios Hospital. After discharge, no fever was recorded, but patient was still noted to be weak looking, irritable and can’t stand nor walk properly. Few hours prior to confinement, he was noted to have crossed eyes hence was brought to this institution and admitted.
For his Post Medical History there was no previous hospitalization. His family has the history of hypertension on the paternal side. His Birth and Maternal History states that he was born in full term to a G2P1 (1001) through NSD at home with the presence of a midwife. They denied having any maternal illness nor fetomaternal complications. For his Nutritional History, he was breastfed from birth until a year and a half and has formula feeding from 1 ½ years until present with Alaska Full Cream Milk. He has the following injections done, BCG and 3 doses of DPT and OPV. His developmental and growth history states that he started to sit at 6 months, crawl at 8 months, stand at 11-12 months and walk at 1 ½ months. Presently he can ride a bike, feed himself and play with scribbles. His Personal-Social History relates that he has a 30 year old mother who is unemployed and a 29 year old father who is also unemployed. He lives with 5 other household member in a 2 bedroom bungalow. He consumes boiled water or Wilkin’s for drinking.
As for this Physical Assessment states that his general survey is awake and irritable. His vital signs are 160 for the pulse rate, 35 for the respiratory rate and 37ºC for the temperature. He weighs 12.8 kg. He was inspected and has seen no rashes and has good skin turgor. During a cephalocaudal inspection it reveals that Aldrin has no sunken eyeballs, has pink palpable conjunctivae, anicteric sclera, no nasolacrimal discharges, has dry lips and moist oral mucosa. For the chest and lungs, he has short of breaths, has harsh breath sounds but no retractions. For...
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