CLINICAL ABSTRACT
General Data: this is the case of Nerido, Merzie Ashlie, Abat, born on 08-14-12; 20 days old, female, Filipino Catholic, from Ili Sur (Pob), San Juan, La Union
Chief Complaint: Blood Tinged Vomitus
Present Illness:
Patient was born to a 26 year old G2P2 (2002) mother with prenatal checkup – twice at their local Health Center, with multivitamins intake and Tetanus Toxoid given. Presence of any maternal illness or antepartum ailments was denied. Patient was born in ITRMC and delivered via NSD with PA of 38 weeks, weight of 2.8 kg, length of 49 cm and AS of 8,9 at 1,5 minutes respectively, BCG and Hep B vaccines given and NBS done (pending result). Upon discharge was advised to come back at OPD (Well Baby check-up) after 1 week but then was lost to follow-up.
Patient was apparently well until, few hours PTA patient suddenly became irritable then upon breast feeding had 2 episodes of blood tinged vomiting hence consult to Bacnotan District Hospital then referred to our institution thus present admission.
Physical Examination:
General Data: awake, irritable, afebrile, in respiratory distress
Vital Signs: CR: 132/min RR: 43/min T: 36.5 C Wt.: 3.1 kg
Skin: no cyanosis, jaundice, pallor
HEENT: patent anterior fontanelle
anicteric sclera, pinkish conjunctivae
no TP congestion
no alar flare
no cervical lymphadenopathy
Chest/Lung : symmetrical in expansion, no retractions
with rales, apical, bilateral
Heart: adynamic precordium, no thrill, no heave, AB 4th ICS LMCL, normal rate and regular rhythm, S1 normal, S2 split, no murmur
Abdomen: globular, soft, nomoactive bowel sounds, no organomegaly
Extremities : full and equal pulses, no gross deformities
Neorolgic: irritable
Cranial nerve: II: pupils equally reactive to light (2mm)
III, IV, VI: no facial assymetry
Motor: 5/5 5/5 Reflexes: ++ ++
5/5 5/5 ++ ++
No clonus, no babinski
Course...