CASE PRESENTATION

(PASTRANA GROUP)

Welch alyne
Incee
kakay
 Objectives
• To be able to present a case of a 11 year old
male presenting with a chief complaint of joint
pain.
• To be able to discuss Rheumatic Fever, its
epidemiology, pathoethiogenesis, clinical
manifestations, diagnostics and management
• To present a journal on the effect of zinc
supplementation in the reduction of
hospitalization of children with pneumonia
 Date of Source of
Interview: Information:
January 21 , 2016 Patient & Mother

Source of
% Reliability: 90%
Referral: None
GENERAL DATA
M.J., 11
years old, Filipino,
Roman
male Catholic
child

Brgy.
September Caninoan,
29, 2004 Pastrana
Leyte

Seen for Painful joint

the 1st swellings of
both lower
time at and upper
the RHU extremities
 HISTORY OF PRESENT ILLNESS

8 days PTC
undocumented
high grade fever
*Still went to
NO self-medicated
with Paracetamol
dry cough school 250mg/5ml
Dyspnea
generalized mild- *Slightly active
moderate Difficulty
but looks weak breathing temporary relief
headache
*Good appetite Easy fatigability of fever and joint
joints pains at paints.
elbows and knees
HISTORY OF PRESENT ILLNESS

5 days PTC
(+) intermittent fever, dry cough, headache, and joint pain

with vague abdominal pain… NO n/v, and diarrhea

slightly swollen R and L elbows characterized as tender and hot
upon palpation

Paracetamol 250mg/ml 1 tbsp. given in 4 doses

Application of liniment afforded temporary relief of abdominal pain

NO CONSULT DONE
 HISTORY OF PRESENT ILLNESS

3 days PTC

(+) on and off fever, headache, joint pains and

abdominal pain

(+) productive cough( yellowish to greenish phlegm)

(+) swollen elbows, knees and ankles

(+) pain upon movement
(+) pallor, (+) loss of appetite, (+) DOB, (+)
palpitations

NO CONSULT DONE
 HISTORY OF PRESENT
ILLNESS

1 day PTC
(+) fever (+) epigastric pain+
yellow to greenish
(+) headache
blood tinged watery
(+) joint pains stool (3-4x)

(+) swollen articular joints (+) Liniment application

(+) limitation of movement (+) joint massage NO CONSULT DONE
(+) easy fatigability (+) intake of Paracetamol
HISTORY OF PRESENT
ILLNESS
Few Hours
PTC
(+) difficulty
walking

Per patients request

(+) CONSULT
PERSONAL HISTORY
• A. Prenatal • B. Birth
History History

born FT
(+) 5 PNCU
cephalic
(+) MV supp. presentation
(+) Tuba intake NSVD
(-) smoking G4P4 (4004) mother
(-) hx of any unusualities trained TBA
home delivery
preboiled scissors
(-) probs encountered
 PERSONAL HISTORY
• (+) vigorous cry & pinkish in color
• (-) jaundice, cyanosis, respiratory distress and
congenital defects
• Meconium stools and urine: first 12 hours of life
C. Neonatal History • Umbilical stump cleaned: 70% alcohol and
betadine;
• sloughed off 5 days after birth
• (-) signs of infection

• (+) exclusively BF up to 2mos.

• 2 mos.: Mixed feeding and Multivitamins
D. Feeding History •
•
4 mos.: Supplemental feeding
12 months: table food
• (-) history of indigestion & diarrhea
• weaned at 1 year old.
 24-hour diet recall
• ½ cup of rice, 1 ½
BREAKFAST matchbox fried fish

• ½ cup of rice, 1
LUNCH matchbox fish (sardines)

• ¼ cup of rice, ½
DINNER matchbox dried fish and
½ cup noodles
 GROWTH & DEVELOPMENT
AGE DEVELOPMENT

3 months social smile, recognizes parents

4-5 months Crawls
5 months appearance of lower central incisors
6 months says “nanay”
7 months Sits w/o support
9 months Walk with support
12 months Walk without support, try to feed himself
18 months Feeds himself
2 years Change by himself
3 years No Enuresis and encopresis, counts 1-20
6 years Draws lines and circles
7 years Knows alphabet, Writes name
8-11 years Currently in grade 5, achiever in school, mingles with
friends, actively participates in sports and in school
program
 BEHAVIOR

Sleeps @ (+) good Sports

9-10 pm; academic minded
wakes up performan Physically
@ 5-6 am ce and
socially
active
 Immunizatio
n Status
(FIC) Past Medical
• BCG, one dose,
no adverse • (-) History of
reaction (@ birth) hypersensitivity
• DPT, three doses, reaction to food • (+) History of
no adverse and drugs cough and colds
reaction • (+) measles @ 1
• OPV, three doses,
year old
with no adverse • (+) chicken pox
reaction
Allergies @ 3 years old
• Hepa B, three
• (+) sore throat 3
doses, no
weeks PTC
untoward
• NO CONSULT
reactions
• Measles, one DONE
dose, no
untoward
reactions (@ 9
mos.)
 PSYCHOSOCIAL
FAMILY HISTORY
HISTORY
FATHER, 37 with cough & Youngest among 5
colds
Grade 3
Amox 500mg BID once with
attack Lives with parents

2 room structured house

Mother, 38 with thyroid problem With electricity and C.R
with maintenance meds H2O from communal deep
well

Firewood used for cooking

2 female; 1 male siblings: Poor hygienic practices (hand
well washing)

Parental side: HPN, BA

Mother, housewife
Maternal side: BA, Heart
Father, farmer (300php/day)
problem

(+) exposure to chronic

Negate others cougher
REVIEW OF SYSTEM
• 25% wt. loss in 8 days of
GEN disease, body weakness
ERAL
• no rashes, no itching
SKIN
HEA • no head injury
D
• no ear discharges
EYES
NOSE
• no nasal discharges, no
&
epistaxis
SINU
SES
 • no redness, no excessive tearing
EARS

• with recurrent sore throat (2x in a

MOUTH & month), no bleeding gums, no sore
THROAT tongue, no hoarseness of voice

• no lump, no stiffness
NECK

RESPIRATORY • with cough, with dyspnea

CARDIOVASCULAR • with two pillow orthopnea, with palpitations

• moves bowel 4-5x in a day yellowish green semi formed

to watery with blood tinged stool, with passage of 1
GASTROINTESTINAL pinkish about 3-4 inches intestinal worms twice, with on
and off abdominal pain, no constipation

GASTROURINARY • urinates to a yellow colored urine amounting to 1-1 ½

cup/void 5-6x a day, no hematuria, no dysuria
TRACT

PERIPHERAL
• no swelling of legs & feet
VASCULAR

• with joint pains at elbows, wrists, knees and

MUSCULOSKELATAL ankles(HPI), with swelling and stiffness
NEUROLOGIC HEMATOLIGIC ENDOCRINE
• no seizures • no easy • no excessive
bruising thirst and
hunger
PHYSICAL EXAMINATION

done at the Rural Health Unit

GEN: Pt. was awake, conscious,
coherent, weak, afebrile, in
cardiopulmonary distress w/ the
ff. v/s:
BP – 80/50 mmHg
RR – 59 cpm (25 mean
±2SD = 6.1)
Temp – 36.7°C(afebrile)
PR – 135 bpm
HR – 135 bpm (93 mean
±2SD = 23. 7)
 ACTUAL IDEAL PERCENTILE RANK

Height 133 cm 124.91 P95

cm

Weight 23 kgs 27.48 kgs P5

Waterlow Classification for wasting

= (actual wt / ideal wt for length) x 100%
= (23 kg / 27.48 kg) x 100%
= 83.7% (mild wasting)
Waterlow Classification for Stunting
= (actual length/ideal length for age) x 100%
= (133 cm / 124.91 cm) x 100%
= 100% (no stunting)
 SKIN & warm, with palmar and
INTEGU plantar pallor, good skin
symmetrical head contour,
MENTS turgor and poor capillary HEAD
black hair evenly distributed
refill (> 3 sec), no clubbing
on the scalp, no dandruff
of finger nails, no rashes nor
lesions.

pale palpebral conjunctivae,

anicteric sclerae, pupils
EYES equally reactive to light at
approx. 2mm, visual acuity
symmetrical pinna aligned EARS
with eyes, no lesion.
of 20/ 20cm at both eyes,
EOM intact, eyes converge
at 5cm, no nystagmus.

NOSE
septum at midline, no nasal
flaring, turbinates not
inflamed
MOUTH & THROAT
• Moist pale lips, pale oral mucosa, uvula &
tongue @ midline, no circumoral lesion, no
gum hypertrophy, no bleeding, no sore
throat, 1 decayed tooth, 2nd molar on the left
lower mandibular area
NECK
• Symmetrical, trachea @ midline, thyroid
gland not palpable, with jugular vein
distension, no cervical lymphadenopathy,
neck supple
PHYSICAL EXAMINATION
CHEST & LUNGS
I – symmetrical chest expansion; prominent rib
cage, no suprasternal, supraclavicular & intercostal
retraction
P –confirmed symmetrical chest expansion, no
lagging
P – resonant all over
A – harsh breath sounds, with fine crackles @
mid to lower lung fields, no wheeze

BREAST & AXILLA

symmetrical, no lesion, no
palpable axillary lymph nodes
HEART
I – dynamic precordium, apical impulse visible at 6th ICS Left MCL
P – apical impulse palpable with a diameter of 3cm at 6 th ICS Left
MCL approx. 6cm from midsternal line, no heaves, no thrills .
A – tachycardic @ 135bpm, regular rhythm, synchronous to radial
pulse, no murmur

ABDOMEN
I – protuberant, no visible pulsation, no visible veins, no bulging
flank, no lesion
P – soft, slightly tender at the epigatsric area, no palpable mass
P – tympanitic, Liver Span – 6cm from Right MCL & 4cm from
MSL, unoblirated traube’s space
A – 20 bowel sounds per minute
 BACK AND
SPINE GENITALIA

spinal column at midline, Uncircumcised, no lesion, no

no lumps, no lesion discharge

PERIPHERAL MUSCULOSKELET
VASCULAR AL
no edema, no pigmentation, no
no joint deformity but with
bounding pulses prominent inflammation of both
Radial Brachial Popliteal Dorsalis Pedis extremities; (+ ) calor, dolor,
Tumor, dolor

R 2+ 2+ 2+ rubor, of inflamed elbows, knees

2+ and ankles; w/ good passive ROM
L 2+ 2+ 2+ however, active ROM is with slight
2+
limitation due to pain
 NEUROLOGICAL
EXAMINATIONS

Mental Status: The patient is conscious, coherent, oriented to time,

place
and person.
Motor Function: good muscle bulk tone; with limitation in the
movement of
extremities due to joint pains.
Sensory: withdrawal of hands upon introducing sharp stimuli when eyes
closed.
 CRANIAL NERVES
I – able to smell & recognize perfume
II– both eyes w/ 20/20 vision on Snellen chart, no field defects
upon
confrontation
II & III– pupils equally reactive to light at 2mm both on direct
& consensual
III, IV & VI – EOM full, no visual field cuts, no nystagmus, no
lid lag, eyes
converge at 5 cm
V motor – able to contract on both sides of the temporal &
masseter muscle
upon clenching teeth
sensory – able to feel and distinguish dull & sharp stimuli

VII motor – symmetrical nasolabial folds upon smiling, able to

raise
eyebrows, able to close eyes tightly
VII – able to hear and repeat whispered words on both ears
IX & X – symmetrical rise of the soft palate & uvula at
midline as the
patient says “ah”, (+) gag reflex.
XI– strong contraction & opposition of the trapezius &
sternocleidomastoid
MENINGEAL SIGNS
PATHOLOGIC

AUTONOMICS
(-) BRUDZINKI’S
SIGN
(-) ANKLE CLONUS
(-) KERNIGS SIGNS
(-) BABINSKI SIGN No excessive
(-) NUCHAL sweating, no
RIGIDITY bowel & bladder
incontinence
 IMPRESSION

RHEUMATIC FEVER
ANEMIA OF UNKNOWN ETIOLOGY
PNEUMONIA
PARASITIC INFESTATION
 PROBLEM CUE LIST
Problem Date Date Problem/ Date Proble
No. of Onset Recorded Diagnosis Resolve m
d Resolve
d

1 JAN. 13,2016 Jan. 21,2016 Fever

Dry cough
Headache
Joint pains
Body weakness
2 Jan. 15,2016 Jan. 21,2016 Abdominal pain
Arthritis

3 Jan. 17,2016 Jan. 21,2016 Pneumonia

RF

4 Jan. 20,2016 Jan. 21,2016 Epigatsric pain

Parasitism
 COURSE IN THE RHU

1ST DAY of
visit
(1/21/2016)
S O A P

(+) history of sore awake, conscious, RF  Diagnostics:

throat coherent, weak, • ESR/CRP
(+) 25% wt.loss afebrile, in Jones Criteria • ASO titer
cardiopulmonary • CXR- PA view
(+) fever Minor:
distress w/ the ff. • 12 lead ECG
(+) cough v/s: • Fever • 2D Echo
(+) painful BP – 80/50 mmHg • Arthralgia • CBC
inflamed upper RR – 59 cpm Major:
and lower joint Temp – 36.7°C • Polyarthritis  Medications:
PR – 135 bpm
extremities • Erythromycin
HR – 135 bpm
Pertinent Findings: 200mg/5ml,
• with palmar and 5.7ml QID after
plantar pallor, meal x 10 days
good skin turgor • ASA 325mg/tab,
and poor 1 tab TID after
capillary refill (> meal x 2 weeks
3 sec)
S O A P

• pale palpebral RF
conjunctivae  Medications:
• moist pale lips, pale
oral mucosa Jones Criteria • MV+Iron syrup, 1
• one decayed tooth, Minor: tsps. 2xaday
2nd molar • Fever • Omeprazole
• apical impulse
palpable with a
• Arthralgia 20mg/tab, 1 tab
diameter of 3cm at Major: OD 30 mins.
6th ICS Left MCL • Polyarthritis before meal
approx. 6cm from  Health Education
midsternal line
• tachycardic @
 TCB anytime
135bpm, regular once with new
rhythm, symptomatology
synchronous to  FF UP ASAP ONCE
radial pulse, NO
murmur WITH RESULTS
• prominent
inflammation of (Referred to MHO)
both extremities;
(+ ) tumor, dolor,
rubor, of inflamed
elbows, knees and
ankles; w/ good
passive ROM
however, active
ROM is with slight
limitation due to
 1ST DAY of visit
(1/21/2016)

S O A P

(+) Cough with awake, conscious, Pneumonia  Placed in O2

whitish to yellowish coherent, weak,
afebrile, in
inhalation 2-3
phlegm lpm via nasal
cardiopulmonary
(+) High grade fever
distress w/ the ff. v/s: cannula
(+) dyspnea on BP – 80/50 mmHg
exertion RR – 59 cpm
(+) 2 pillow  Diagnostics:
Temp – 36.7°C
orthopnea PR – 135 bpm • CBC
(+) 25% wt.loss HR – 135 bpm • CXR-PA view
(+) loss of appetite O2 sat @ RA- 94%
(+) easy fatigability Pertinent Findings:
Chest and Lungs
 Medications:
• harsh breath • Erythromycin
sounds, slight 200mg/5ml,
dullness @ lower
lung field, with fine
5.7ml QID after
crackles @ mid to meal x 10 days
lower lung fields  Advised for
• Tachycardic, regular pneumococcal
rhythm,
synchronous to
vaccination once
radial pulse stable & or
 1ST DAY of visit
(1/21/2016)

S O A P

(+) headache awake, conscious, Anemia , etiology  Placed in O2

coherent, weak,
(+) history of afebrile, in
inhalation 2-3
pallor cardiopulmonary unknown lpm via nasal
(+) loss of distress w/ the ff. v/s: cannula
appetite BP – 80/50 mmHg ( IDA vs. Intestinal
RR – 59 cpm
(+) easy Parasitism  Diagnostics:
Temp – 36.7°C
fatigability PR – 135 bpm 2ndary ) • CBC
(+) body HR – 135 bpm • Whole
weakness O2 sat @ RA- 94% Abdomen UTZ
Pertinent Findings:
(+) DOB • with palmar and • Stool exams
(+) dyspnea on plantar pallor, good  Medications:
exertion skin turgor and • MV+Iron
poor capillary refill
(+) palpitations (> 3 sec)
syrup, 1 tsps.
(+) passage of • pale palpebral 2xaday
blood tinged stool conjunctivae  Health
(+) passage of 1 • moist pale lips, pale Education
oral mucosa
pinkish about 3-4  TCB once with
• tachycardic @
inches intestinal 135bpm, regular result
worms twice rhythm,
synchronous to
radial pulse
 1ST DAY of visit (1/21/2016

S O A P
awake, conscious, Parasitic
(+) fever coherent, weak,  Diagnostics:
afebrile, in
Infestation
(+) abdominal pain • Stool exams with
cardiopulmonary
(+) pallor
distress w/ the ff. v/s: occult blood
(+) 25% wt.loss
(+) loss of appetite
BP – 80/50 mmHg  Medications:
RR – 59 cpm
(+) easy fatigability Temp – 36.7°C
• MV+Iron syrup, 1
(+) passage of PR – 135 bpm tsps. 2xaday
blood tinged stool HR – 135 bpm  Health Education
(+) passage of 1 Pertinent Findings:  TCB once with
pinkish about 3-4 • with palmar and
plantar pallor, good result
inches intestinal
skin turgor and
worms twice poor capillary refill
(> 3 sec)
• pale palpebral
conjunctivae
• moist pale lips, pale
oral mucosa
• abdomen is
protuberant
  STABILIZED
 DISCHAGED WITH HOME INSTRUCTIONS
 INSTRUCTED TO CLOSED WATCH
PATIENTS CONDITION
 DOCUMENT SYMPTOMS AND REFER
ONCE NOTICED
 MONEY??? MEDICINES???
( Advised to tap politicians
for assistance)

 COMPLIANT TO
ANTIBIOTIC
BUT NOT TO
ASA
 COMPLIED
FOLLOW UP AFTER 10
BASIC LABS DAYS WITH RESULTS
 February 1, 2016

S O A P
RESULTS

(+) painful inflamed awake, conscious, RHEUMATIC

upper and lower coherent, conversant,
sitting on bed,afebrile,
FEVER,
joint extremities
not in cardiopulmonary
(-) OTHER
distress w/ the ff. v/s: improving
SUBJECTIVE BP – 90/50 mmHg
COMPLAINTS RR – 24 cpm
Temp – 36.7°C
PR – 94 bpm
HR – 94 bpm
Pertinent Findings:
• (+) slight palmar
and plantar pallor,
good skin turgor
• slightly pale
palpebral
conjunctivae
• moist pale lips,
slightly pale oral
mucosa
• apical impulse not
CXR RESULT
S O A P

• NORMAL regular Rheumatic

rhythm,  Medications:
synchronous to
Fever,
radial pulse, NO improving • Start Benzathine
murmur PCN 1.2 MU
• prominent deep IM every 21
inflammation of
both extremities;
days
(+ ) calor, dolor, Continue the ff.
rubor, of inflamed meds:
elbows, knees and • ASA 325mg/tab,
ankles; w/ good
passive ROM 1 tab TID after
however, active meal x 6 weeks
ROM is with slight • MV+Iron syrup, 1
limitation due to
pain
tsps. 2xaday
 Follow up every
after 21 days for
Pen G injection
for 5 years or
until age 21yrs
old

(Referred to MHO
and C.I)
 S O A P

(+) occasional awake, conscious, Pneumonia ,

non productive coherent, conversant,  Medications:
sitting on bed, afebrile,
improved
cough Continue
not in cardiopulmonary
(-) OTHER
distress w/ the ff. v/s: • MV+Iron syrup, 1
SUBJECTIVE BP – 90/50 mmHg
COMPLAINTS tsps. 2xaday
RR – 24 cpm
 Advised for
Temp – 36.7°C
PR – 94 bpm pneumococcal
HR – 94 bpm vaccination
O2 sat @ RA- 98-99%  TCB anytime
Pertinent Findings:
Chest and Lungs once with
• harsh breath sounds, unusualities
(-) crackles, (-)
wheeze, Normal
regular rhythm of HR
( Referred to MHO )
synchronous to radial
pulse
 CXR RESULT
CBC

12.33

Mild form of bronchitis with some degree of air

trapping
No hilar adenopathy
 Whole
Abdomen UTZ
Result
 S O A P

(+) slight pallor awake, conscious,

coherent, conversant,
(+) slight easy sitting on bed,
fatigability afebrile, in
cardiopulmonary
distress w/ the ff. v/s:
BP – 90/50 mmHg
RR – 24 cpm
Anemia secondary
Temp – 36.7°C to parasitism
PR – 94 bpm
HR – 94 bpm Anemia slightly
O2 sat @ RA- 98-99%
STOOLFindings:
Pertinent PLAN
EXAMS: ( JANUARY resolving
29, 2016 )
• (+) slight palmar
and plantar pallor,
 Medications:
good skin turgor RESULT
• Consistency:
Stool
• slight MV+Iron syrup,
pale semi1 formed
palpebraltsps. 2xaday
Color: Brown
conjunctivae
(+)
Follow
• moist pale lips,
up after
Trichuris 1
Trichiura
slight(+) month
Enterobius
pale oral for repeat
Vermicularis
mucosa (+)CBC
Ascaris Lumbricoides
• NORMAL regular
 TCB once with other
rhythm HR
problems
synchronous to
radial pulse
 S O A P

awake, conscious, Parasitic

(+) abdominal pain coherent, conversant,  Medications:
sitting on bed, afebrile,
Infestation
(+) slight pallor • MV+Iron syrup, 1
not in cardiopulmonary
distress w/ the ff. v/s: tsps. 2xaday
BP – 90/50 mmHg • Mebendazole
RR – 24 cpm
Temp – 36.7°C
100mg/tablet, 1
STOOL EXAMS:
PR – 94 bpm( JANUARY 29, 2016 ) tablet BID for 3
HR – 94 bpm days
Pertinent Findings:  Health Education
RESULT
• (+) slight palmar
 Advised TCB for
Stool Consistency: semi formed
and plantar pallor
• (+) slight pale repeat stool
Color: Brown
palpebral exams
(+) conjunctivae
Trichuris Trichiura
( Referred to C.I
(+) Enterobius Vermicularis
• moist pale lips,
slight pale oral when to start
(+) Ascaris Lumbricoides
mucosa treatment )
• abdomen is
protuberant, soft,
non tender
Problem
PROBLEM
Date Date
CUE
Problem/
LIST
Date Proble
No. of Onset Recorded Diagnosis Resolved m
Resolve
d
1 Jan. 13,2016 Jan. 21,2016 Fever Jan.25,2016 Resolution
Dry cough Feb.1,2016 after 4 days; 3
Headache Jan.25,2016 weeks & 6
Body weakness Feb.1,2016 weeks
Joint Pains April 2nd week thereafter
2016

2 Jan. 15,2016 Jan. 21,2016 Abdominal pain Feb. 2nd week After 2nd week
2016 Resolved after
Arthritis April, 2nd week 6 weeks of
2016 treatment

3 Jan. 17,2016 Jan. 21,2016 Pneumonia Feb.1, 2016 After 3 weeks

Symptoms
RF Feb.1,2016, free after 2
improving months

4 Jan. 20,2016 Jan. 21,2016 Epigatsric pain Feb. 1,2016 Symptoms

Parasitism Feb. 3rd week free after 3
2016 weeks of
treatment
 OTHER PLANS OF MANAGEMENT
 Health Advocacy Campaign
 Tap different stakeholders for assistance

DONE
( DSWD region, PCSO, Politicians, NGOs )
 Endorsement to DSWD local for
assistance
 Issuance of Medical Abstract
 Home Visit
 PATIENT’S UPDATE
 Treatment started February
1,2016
 Ff up done every month for 4
months
 Complied 3 months injection
 May 2016- Shifted to PO
meds of Sumapen
500mg/capsule, 1 capsule OD
 No ff- up done until present
 MAUPAY NGA
PAGKATUROG…..
BALITS NAMAMATI
MAN KAMO!!!
SALAMAT