Download Medicineatient V. H a 13-year-old female student residing in Sta. Barbara, Pangasinan. She and more Summaries Medicine in PDF only on Docsity!
LYCEUM-NORTHWESTERN UNIVERSITY
FRANCISCO Q. DUQUE MEDICAL FOUNDATION
COLLEGE OF MEDICINE
A.Y. 2022-
PEDIA II WARD WORK
INDIVIDUAL REPORT
PRECEPTOR: DR ROCHELLE CASTRO
WW SECTION: A
GROUP NUMBER: GROUP 6
NAME: MAYUSHREE THENGAL
DATE OF HISTORY TAKING: JANUARY 23, 2024
GENERAL DATA:
Patient V. H a 13-year-old female student residing in Sta. Barbara, Pangasinan. She was born on May 2, 2010, at R1MC Arellano. The patient was admitted to R1MC on January 22, 2024, at 10 pm. Date of Interview: January 23, 2024 Time of Interview: 1:30pm Informant: Patient herself CHIEF COMPLAINT: SNAKE BITE HISTORY OF PRESENT ILLNESS: 3 hours PTA: At around 7 pm, the patient was walking with her cousin when the cousin
accidentally stepped on a triangular-nosed(not broad), brown snake measuring 19-20 inches ; and the patient was bitten on the right ankle. Within 3 minutes after the bite, the patient experienced dull pain rated at 5/10 then numbness from the bite site to the shin area. After 2 minutes of running to their house, she washed the bite site with water (no soap used) for 2- minutes subsequently the numbness minimized. Following her aunt's advice, garlic was applied and rubbed onto the bite site. They also tied up her leg , above the affected area. 2 hours PTA: The patient was then rushed to the nearest community hospital, assessed and washed the affected area, then advised to send the patient to our institution(R1MC) for the reason of unavailability of vaccine/drugs. 1 hour PTA: They transported the patient to R1MC via barangay patrol car. The patient was injected on the left arm (deltoid) with medication, but the relative didn't know or recall the purpose of the medication used. At 10 pm, the patient was subsequently admitted. REVIEW OF SYSTEMS: CONSTITUTIONAL (-) Fever (-) Fatigue (-) Weight gain/loss (-) Poor oral intake SKIN (-) Rash (-) Pruritus (-) Dryness (-) Pigmentation HEENT HEAD: (+) Headache (-) dizziness (-) lightheadedness EYES: (-) Pain (-) redness (-) lacrimation EARS: (-) Hearing problem (-) Earache (-) Discharge NOSE: (-) Discharge (-) Epistaxis (-) pain THROAT/ MOUTH: (-) Bleeding gums (-) Mouth sores (-) Sore throat NECK -) Neck pain (-) Cervical muscle stiffness (-) Lump in the neck region RESPIRATORY (-) Dyspnea (-) cough (-)chest pain CARDIOVASCULAR (-) Heartburn (-) Edema (-) Cyanosis GASTROINTESTINAL (-)Constipation, (-) Hematemesis, (-) Dysphagia, (-) Hematochezia, (-) melena, (-) Hemorrhoids GENITOURINARY (-) Dysuria (-) Nocturia (-) Polyuria (-) Gross Hematuria (-) Incontinence (-) Urinary Retention (-) Urinary Urgency (-) Tea-Colored Urine
HEADSSSS:
HOME
V.H. lives with her mother and 3 siblings, among whom 2 are younger brothers and one younger sister. They live in a concrete house with five of them sharing one room. Her parents have been separated for 5 years now. Her father left their current house when she was 8 years old. Her mother has worked as an OFW but returned once she turned 10. She claims that the relationship at home is good and strong. She also agrees to share her feelings during stress with her mother. EDUCATION She is currently in grade 8 and said that other than the subject mathematics, she has no difficulties that she faces in school. She claims that she never failed a grade and has no record of poor attendance. She informed us that she would fidget sometimes during recitations in class. When asked she had an average of 15 minutes attention span. She also mentioned that she is sometimes late in submitting her assigned works. She claims that she rates her grade performance as moderate with Filipino being her favorite subject while math being the least. ACTIVITIES V.H. is into watching movies and dramas while also being keen on playing badminton. DRUGS She claims to not have any friends or family members who use tobacco, alcohol or any drugs as well she claims the same for herself. However, when asked she said when her father was still living with them, he had drinking and smoking issues. SEXUALITY V.H.’s sexual orientation is female and never been involved in an intimate act. She is interested in the opposite sex. SUICIDE/ DEPRESSION She has no sleep disorder or appetite changes. The only time she has a feeling of boredom is during her math class. The patient claims to have never had suicidal thoughts. SAFETY She said that she felt safe at her house, neighborhood and at her school. There is no history of her getting bullied or picked on by her schoolmates. SPIRITUALITY The patient’s family is catholic and are attending mass every sunday. But she also claims that they do miss prayers sometimes.
FAMILY HISTORY:
The patient’s father is 36 years old, mother is 31 years old. Both are alive and healthy. Hypertension on the paternal side. No history of diabetes, asthma, heart disease or hematological disease noted in the family. The patient has 3 siblings and she is the eldest. Her younger sister is 12 years of age and 2 younger brothers 10 and 8 years of age. All the siblings are in a good state of health. SOCIOECONOMIC & ENVIRONMENTAL HISTORY: The patient lives with her mother and siblings in a concrete house. No exposure to cigarette smoke or pollutants. PHYSICAL EXAMINATION: GENERAL SURVEY: Patient is awake, pleasant, cooperative, and not in cardiorespiratory distress VITAL SIGNS: VS PATIENT’S VALUE Temperature 36.5℃ Heart Rate 87 bpm Respiratory Rate 24 bpm Oxygen saturation 98% (room temperature) Blood pressure 100/70 mm Hg ANTHROPOMETRIC DATA: Height: 156 cm Weight: 41 kg
Z-score: 0 (median) Interpretation: NORMAL REGIONAL BODY EXAMINATION: SKIN Skin is warm, and dry, slight pallor, and no lesions.
HEAD Normocephalic without scalp lesions, symmetrical, no abnormal masses EYES ● Pink palpebral conjunctiva, anicteric sclera, EOMs are intact , no strabismus or nystagmus. Symmetrical pupils and react to light and accommodation EARS ● Ears are symmetrical. No erythema, lesions and no discharge noted. Clear external auditory canals. Pinnae normal is shape and contour. Hearing normal whispers. NOSE the nose is symmetric and with no deformity. No sinus tenderness, normal midline septum.
ABDOMEN ● Inspection : flat abdomen, no presence of prominent vessels nor visible pulsation, no scar ● Auscultation : normoactive with 5 bowel sounds per minute that is gurgling in nature and occurs in 10-12 second intervals, no bruits, no venous hum, nor friction hub. ● Percussion : tympanic (except in some area on the RUQ due to the presence of the liver). ● Palpation : soft, warm, no guarding, no direct nor rebound tenderness, no hepatomegaly, and splenomegaly, no palpable mass noted MUSCULOSKELET AL ● Inspection: there is presence of 2 fang’s mark at the posterior right ankle, there is no edema, erythema, nor ecchymoses. ● Palpation: warm, no tenderness, nor stiffness NEUROLOGICAL EXAMINATION: MSE: Patient is awake and well orientated GCS: 15 CRANIAL NERVES CN Procedures/ Tests Responses I Olfactory nerve Smelling intact II Pupillary reflex Pupils are equal, round, reactive to light III, IV, VI M: lateral, medial, upward and outward gaze; opening of eye Presence of 4 cardinal gaze; no nystagmus, intact EO muscles
V Corneal reflex Intact VII Do facial expressions No facial weakness nor asymmetry VIII Finger snapping/ Hearing Patient respond to sound IX and X Ability to swallow; gag reflex Intact Uvula in midline XI Shoulder shrug test Intact XII Observation of tongue movement Intact MOTOR EXAMINATION: (L) (R ) UE 5/ 5/ LE 5/5 5/ DIAGNOSIS: SNAKE BITE WITH NO SIGN ENVENOMATION SALIENT FEATURES: SUBJECTIVE OBJECTIVE (+) history of snake bite (+) dull pain on (R) ankle (+) numbness on (R) ankle upto shin area (+) headache,
PE
● (+) fang’s mark at the posterior right ankle, ● (-) edema, erythema, nor ecchymosis.right, lower extremity ● (-) paralysis ● (-) ptosis
