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FAR EASTERN UNIVERSITYDR. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER

Regalado Ave., Corner Dahlia Street, e!t Fairvie" #$e%on Cit& '''(Tele)hone N$*+er -/010'2

DEPARTMENT OF CHILD HEALTH

CLINICAL 3ISTORY

DATE:Ma& '4, 1'4INFORMANT:MotherRELIA5ILITY (167ENERAL DATA

Al8on!o, A&e!!a Ni9ole :anal, 4 &ear! old, Fe*ale, Fili)ino, Ro*an Catholi9, +orn on ;$ne 4, 11< inCa+anat$an Cit&, 9$rrentl& re!iding at Lot 2 5lo9= 4 Sevilla Street, S$**erville S$+divi!ion,Ma&a*ot, Anti)olo Cit&, ad*itted 8or the '-thti*e in FEU0NRMF Medi9al Center on Fe+r$ar& ', 1'4.

CHIEF COMPLAINT: For intrathe9al 9he*othera)h&

3ISTORY OF :RESENT ILLNESS

The )atient i! a diagno!ed 9a!e o8 A9$te L&*)ho+la!ti9 Le$=e*ia FA5 L' !in9e ;an$ar&1'-, "hen the )atient>! grand*other noti9ed )ete9hial ra!he! on her lo"er e?tre*itie! a!!o9iated"ith di%%ine!!. No a99o*)an&ing !&*)to*! !$9h a! 8ever, +od& *alai!e, diarrhea or a+do*inal )ain.

The grand*other al!o noted a @049* he*ato*a on her right lo"er =nee. The )atient al!o haddi9$lt& 9li*+ing !tair! "hen the grand*other noti9ed her "ith di9$lt& o8 +reathing "hen $!ingthe !tair!. She "a! +ro$ght to a )rivate )aediatri9ian and "a! re8erred to a :ediatri9 3e*atologi!t,!he "a! then diagno!ed "ith A9$te L&*)ho+la!ti9 Le$=e*ia. Ind$9tion )ha!e o8 ( da&! "a! !tarted.She "a! given Vin9ri!tine '.@*gB*l IV, :redni!one -1*gB*l :O, L0a!)argina!e 4,111$B*l and IVMethotre?ate ' *g "a! !tarted. She "a! al!o diagno!ed "ith M$ll$!9$* Contagio!$* and "a!

given Sali9&li9 a9id 9rea*, a))lied t"i9e a da& a8ter +athing and M$)ir$9in to)i9al oint*ent onae9ted area! "hi9h aorded te*)orar& relie8.

On Mar9h '(, 1'-, )atient "a! ad*itted 8or the nd ti*e in o$r in!tit$tion 8or9he*othera)h&, !ta&ed in the "ard 8or da&! and "a! given intrathe9al Methotre?ate '*g, 40Mer9a)to)$rine @1*gBta+ ta+ at +edti*e, Cotri*o?a%ole !$!)en!ion -11*gB(1*gB@*l, @*l ever&' ho$r!, N&!tatin !&r$) '*l gargle, M$)ir$9in oint*ent a))lied to ae9ted area 2 ti*e! a da&,Mi9ona%ole oral gel a))lied to ae9ted area 2 ti*e! a da&, I*i$i*od 9rea* @6 at +edti*e Monda&to Frida& 8or *onth!.

She "a! ad*itted la!t Ma& -, 1'- "hen !he 9o*)leted her dela&ed inten!ive )ha!etreat*ent "ith Vin9ri!tine '.*g IV )$!h, Do?$r$+i9in 1*g '1199 D @ to r$n 8or 21 *in$te!,De?a*etha!one -*gBta+ ta+! on9e a da& a8ter 8$ll *eal, AlGMgH3O2 t!) 1 *in$te! a8ter *eal!a8ter +edti*e, C&9lo)ho!)ha*ide (-1*g @199 D@ to r$n 8or ho$r!, Cotri*o?a%ole !$!)en!ion-11*gB(1*gB@*l, @*l ever& ' ho$r!, N&!tatin S&r$) '*l gargle, M$)ir$9in oint*ent a))lied toae9ted area! 2 ti*e! a da&, Mi9ona%ole oral gel a))lied to ae9ted area 2 ti*e! a da&.

She "a! ad*itted on Se)te*+er ', 1'@ 8or !ingle intrathe9al 9he*othera)h& o8Mida%ola* @*g TSIV 21 *in$te! +e8ore intrathe9al )ro9ed$re, eta*ine @*g TSIV +e8oreintrathe9al )ro9ed$re, Methotre?ate '*g and Vin9ri!tine '.*g TSIV. She "a! 9ontin$ed to 40Mer9a)to)$rine /@*gBta+let, ' ta+let on9e a da& 8ro* Monda& to Sat$rda&, 9o*)lete +lood 9o$nt"ith )latelet 9o$nt, 9ere+ro!)inal J$id total 9o$nt and dierential 9o$nt and ASO "ere done "hi9hrevealed nor*al re!$lt!.

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:atient "a! !een in FEU0NRMF O:D on Nove*+er '4, 1'@, "ith a diagno!i! o8 URTI05a9terial, and "a! given Ce8$ro?i*e at 2.( *gB=gBda& 5ID 8or '1 da&! and Loratidine :hen&le)hrine !&r$) 4.@*l CID 8or @ da&!.

:atient "a! ad*itted at FEU on Fe+r$ar& 8or the '2th ti*e at FEU0NRMF Medi9al Center 8or

!9hed$led intrathe9al 9he*othera)&. :atient "a! 9ontin$ed "ith Clatithro*&9in @1*gB@*l, -*lt"i9e a da& 8or - *ore da&!, oral *edi9ation! !$9h a! DM:, Methotre?ate and :redni!one "ere al!o9ontin$ed. :atient had do*e !ha)ed 9entrall& $*+ili9ated )a)$le! on !everal area! o8 the +od&,)arti9$larl& on the l$*+ar area, el+o"! , =nee! and 8a9e. She "a! !tarted on :hen&le)hrine 3Cl 5ro*)henira*ine *aleate GRe*edrilH @*l, three ti*e! a da& 8or @ da&!. Other *edi9ation! "ere9ontin$ed. Intrathe9al Metothre?ate and Vin9ri!tine "ere tolerated "ell.

On Mar9h 1'4, )atient "a! ad*itted 8or $rinar& tra9t in8e9tion. :atient "a! !tarted onCe8tria?one 4@1*g TSIV ANST ever& ' ho$r!, Citiri%ine, '*gB*l @*l on9e a da& 8or / da&!.

At )re!ent, )atient ha! good a9tivit&, good a))etite. :atient had a !ingle e)i!ode o8)roKe9tile vo*iting o8 )revio$!l& inge!ted 8ood a*o$nting to ' 9$), non0+ilo$!, non0+lood&. No!$+Ke9tive 9o*)laint! o8 di%%ine!!, heada9he, 8ever, a+do*inal )ain and diarrhea.

:AST MEDICAL 3ISTORY

11

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O:V 2 At a )rivate 9lini9

Mea!le!:ne$*o9o99alRotavir$

'''

At a )rivate 9lini9

NUTRITIONAL 3ISTORY

:atient "a! on *i?ed 8eeding 8ro* +irth $) to &ear! o8 age. She "a! !tarted on S48or*$la *il= $) to 4 *onth! "ith '' dil$tion, 9on!$*ing 20- o$n9e! )er da&. Co*)li*entar& 8ood"a! !tarted at 4 *onth!. There "a! no en9o$ntered di9$lt& o8 8eeding. :re!entl& !he 9on!$*e!a+o$t 20( !)oon8$l! o8 ri9e "ith viand.

DEVELO:MENTAL MILESTONES

Age 7ro!! Fine Lang$age :er!onal andSo9ial

5irth Fi?ate 8a9e or lightin line doll>! e&e

on t$rning

NBA NBA NBA

( "ee=! Follo"! o+Ke9t!'(1 degree!

NBA Coo! S*ile! on !o9ial9onta9t

( "ee=! Sit! +rieJ& "ith!$))ort

Tran!8er o+Ke9t!hand to hand

:ol&!&lla+i9 vo"el!o$nd! 8or*ed

:re8er! *otherEnKo&! *irror!

' &ear old al=! alone9ra"l! $)!tair!

Ma=e! line "ith9ra&on!In!ert! )ellet! in+ottle

;argonFollo"! !i*)le9o**and!

3$g! )arent!Indi9ate! !o*ede!ire! or need!)ointing

&ear old R$n! "ellal=! $) anddo"n!tair!

To"er o8 < 9$+e! no"! age and!e?Co$nt! 2 o+Ke9t!9orre9tl&

:la&! !i*)lega*e!a!he! hand!

- &ear old 3o)! on one 8ootCli*+! "ellThro"! "ell

Co)ie! 9ro!! and!$are Co$nt! - 9oin!a99$ratel&Tell! a !tor&

:la&! "ith !everal9hildren

@ &ear old S=i)!Dre!! and $ndre!!5r$!he! teeth

Co)& triangle,9ir9le and !$are

S)ea= 9learl&$!ing *ore9o*)le?!enten9e!

EnKo&! )la&ing"ith other 9hildrenShare! and ta=e!t$rn!

:ERSONAL SOCIAL 3ISTORYShe i! a )rod$9t o8 a )lanned )regnan9&. She $!$all& !lee)! 8or

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HEENT: :in= )al)e+ral 9onK$n9tiva, "hite !9lerae, inta9t t&*)ani9 *e*+rane!, *oi!t li)! and *oi!t+$99al *$9o!a, "ith )in= )har&ngeal "all!NECK : S$))le, No )al)a+le l&*)h node!, no )al)a+le *a!!e!LUNGS: S&**etri9al 9he!t e?)an!ion, no retra9tion!, 9lear +reath !o$nd!, good air entr&HEART: D&na*i9 )re9ordi$*, ta9h&9ardi9, reg$lar rh&th*, no *$r*$r!ABDOMEN:

So8t, Jat, "ith nor*oa9tive +o"el !o$nd!, non0tender, no *a!!e!, no organo*egal&EXTREMITIES: No gro!! de8or*itie!, 8$ll and e$al )$l!e!, CRT Q !e9ond!SKIN: good !=in t$rgor, "ith do*e !ha)ed 9entrall& $*+ili9ated )a)$le! on !everal area! o8 the+od&, )arti9$larl& on the l$*+ar area, el+o"! , =nee! and 8a9e

NEUROLO7IC EPAMINATION

Cerebrum: Con!9io$!, Coherent, "ith a 7CS '@ GE-, V@, M4H Oriented to ti*e, )la9e, and )er!on.Inta9t i**ediate, re9ent, re*ote *e*or&.

Cerebellum: No n&!tag*$!, "ith $n!tead& gait, "a! a+le to do ra)id alternating *ove*ent.

CRANIAL NERVESI Inta9t !*ellII 02 ** e$all& rea9tive to lightIII IV VI Inta9t e?trao9$lar *$!9le!V a! a+le to 9len9h teeth,"ith 9orneal +lin= reJe?VII No 8a9ial a!&**etr&, 9an !*ile, 8ro"n, a+le to )$ 9hee=!VIII Inta9t gro!! hearing, a+le to +alan9eIX X ith gag reJe?, $v$la at *idline, 9lear )honationXI Can !hr$g !ho$lder! "a! a+le to t$rn head 8ro* !ide to !ideXII Tong$e at *idline

Motor 8$n9tion Sen!or& 8$n9tion DTR

@B@ @B@ '116 '11 6

@B@ @B@ '116 '116

Sign! o8 *eningeal irritation No n$9hal rigidit&, No ernig !ign, No 5r$d%in!=i !ign

ReJe?e! G0H 5a+in!=i, G0H5r$d%in!=i, G0HN$9hal rigidit&

ASSESSMENTA9$te L&*)ho+la!ti9 Le$=e*ia

:LAN OF CARE

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:lea!e ad*it to !ervi9e "ard $nder the !ervi9e o8 Dr.RondillaBDa9$laB7en$inoB:angilinanBA$inoBAngele!Diet a! toleratedFor 9o*)lete +lood 9o$nt "ith )latelet doneFor $rinal&!i!For intrathe9al 9he*othera)h& Metothre?ate to*orro"

3old oral Metothre?ate on S$nda&eigh )atient no" then dail& and re9ordMonitor vital !ign! ever& - ho$r and re9ordMonitor in)$t and o$t)$t ever& !hi8t and re9ordRe8er a99ordingl&.

Dr. RondillaBDa9$laB 7en$inoB :angilinanB A$inoBAngele!B

;IIC TolentinoBCo0;IIC Vi9toria B Co0 ;IIC Vi9aldo