HEZER E.

NECESITO MED 2015-B: Pedia Preceptorial Case 4

July 29, 2013

UERMMMCI HOSPITAL University of the East Ramon Magsaysay Memorial Medical Center, Inc College of Medicine

Date of Admission: July 25, 2013 Date of interview July 26, 2013. PATIENTS PROFILE: S.S . is a 5 y/o, Filipino male, a Roman Catholic by religion and live in Sta. Ana, Manila, was admitted this July 25, 2013 as his first hospital admission. Source and reliability: The mother is the primary source of data and is deemed valid and with 90% reliability. CHIEF COMPLAINT: Enlargement of the right lateral side of scrotum of 2 months duaration. HISTORY OF PRESENT ILLNESS: 2 months PTA, the mother noticed enlargement of pts .right scrotum, slightly firm and only with minimal pain when manipulating. No signs of inflammation like redness, warmth and fever. Activities like playing, eating and sleeping are not affected. No pain upon urination, or any change on urine quality and bowel movements. Went to Sta. Ana Hospital, on which manual retraction was done by the doctor but only a little relief was made. The next day, went to UERM for consult, manual manipulation was done by the doctor and UTZ was carried out. Hydrocele was the diagnosis and advised them for a surgery (hydrocelectomy). 1month PTA, the hydrocele was noticed to be smaller compared to previous size. A day before admission the mother went to UERM hospital for the scheduling of surgery. Hence, admission was done the next day. Pertinent positives and negatives: enlargement of the right scrotum with remission the progressed bilaterally, but more prominent to the right. Firm in consistency with pain on manipulation, redness and warmth on site is not observed. No fever, change in bowel and urination, no affectation on daily activities. TEMPORAL PROFILE

Size Increasing

Hydrocele (right scrotal sac) decreasing 2 months PTA 1 month PTA 1 day PTA

BIRTH HISTORY Mother is a G3P1 (T0P1A2L1). Not drinking alcohol,smoking nor taking any elicit drugs. The pregnancy was planned, however the mother didnt receive any immunizations or vitamins, o disease occurred during pregnancy. T.Y. is 34 weeks AOG, with birth weight of 4 lbs., via CS delivery. Claimed to have no complications during delivery. Length and APGAR score was unrecalled though claimed to have absence of bluish or yellowish skin discoloration. Been incubated for a week in the hospital. FEEDING HISTORY Breast fed up to 3 moths only, the mother decided to stop due to pain felt while breastfeeding. Shifted to formula milk (S26) up to present. Solid foods started by 6 months of age. And most of his diet consist of 2 glasses of milk (250 + 2 scoops each) per day with usually 2 cups of rice and viand. Prefered foods consist of chicken, vegetables, meat and fish. Currently taking multivitamins syrup (cherifer) and previously memo plus vitamins. No food or medicine allergies. Urine claimed to be normal but with unrecalled frequency, usually defecate once a day with formed brown stool. DEVELOPMENTAL MILESTONES Most of the data concerning development are unrecalled y the informant but what she remember was at his 1 year and four months old, he already can walk along. Presently on grade one school, with high grades on his subjects, with good conduct inside the school, knows how to read and write and able to draw a complete human face Including the feature of the face, he is right handed. Also able to dress self. IMMUNIZATIONS: Claimed by the informant to have completed though unable to name and described the vaccines given. PAST DISEASES: Had his first diarrhea at 9 months of age (unrecalled management) and the two episodes with unrecalled dates. Contracted pneumonia at his 1 year and 6months of age. Diagnosed to have astigmatism + myopia at 4 years of age and provided with glass, diopters of 100 OD 50 OS and astigmatism 170mmHg. SOCIAL/ ENVIRONMENT HISTORY Live in Sta Ana Manila at his grandmothers house (maternal side). The house is two storey on wh ich there are ten nd residents including his family and closed relatives. They stayed at the 2 floor on two rooms made of wood and cement. Their comfort room had flush, and with good source of water at nawasa and current at Meralco. The environment are claimed to be crowded but peaceful, the barangay is located near Pasig river though their house is a little bit far from the river. Their garbage had been collected twice a week. Two of his house mates are smoking cigarettes including his mother, uncle and grand father. His father was already away for 2 years as an OFW in Bahrain. Working as salad maker earning P70,000/month but then only P10,000 had been remitted to his wife (reasons was unknown). The money as claimed is insufficient for their needs and so some monetary help had been provided by his aunt (his fathers sister). His mother (the informant), 33 years old, BS psych graduate and currently without job. A full pledged home maker. ROS (REVIEW OF SYSTEM) Theres no pertinent positives and negatives except those that are already presented in past medical history (diarrhea, pneumonia, and visual impairment) which was managed and his current health situation. Physical Examination a. General Survey

Patient is awake, alert, conscious, coherent, cooperative, and playful without signs of cardiorespiratory distress. He is oriented to place, person, and time. b. Vital Signs Vital Signs BP: not assessed PR: regular 101bpm HR: regular 106 (using stethoscope) RR: 22 cpm Temperature: 36.2 deg Celsius (axillary) Anthropometrics Weight: 24kg Height: 111.5cm BMI: 19.83 Normal b. Skin and Appendages Skin is fair, without scars or lesions, moist, warm to touch and with good turgor. Hair is black, coarse, and evenly distributed without infestations. Nailbeds are pink without signs of clubbing and a capillary refill time of <2 seconds. c. Head No lesions, masses, or tenderness noted. d. Eyes Patient wears corrective glasses with __OD 100 OS 50__ diopter. No lesions, discharges, ptosis, excessive tearing, periorbital edema, discolorations and other gross abnormalities noted. No tenderness on palpation,with anicteric sclera, pinkish palpebral conjunctiva, and smooth and clear cornea and lens. Pupils are 3-4mm in diameter, equally reactive to light and accomodation. Fundoscopy revealed positive ROR on both eyes with clear media. e. Ears Gross hearing intact, normoset ears, patent external ear canal, both tympanic membranes were visualized, pinkish gray in color. No ear lesions,discharge, or tenderness. f. Nose No gross deformities, discharges, or lesions seen. Symmetrical canal folds and septum at midline noted. g. Mouth Lips are pink and moist without fissures. Gums are pink and moist. Tongue at the midline. h. Neck Neck supple. Trachea at midline. Thyroid gland non-palpable. Cervical lymph nodes nonpalpable. i. Chest and Lungs No deformities noted over the posterior chest area. Equal tactile fremitus, resonant on percussion, and clear breath sounds on auscultation over all lung fields. No adventitious breath sounds heard. j. Heart No deformities on anterior chest wall. No heaves and thrills noted. PMI and apex beat at 4th ICS LMCL. Distinct S1 and S2 heard. No adventitious heart sounds heard. JVP: k. Abdomen Abdomen is flat to slightly globular, without scars, lesions, or deformities, and with normoactive bowel sounds. No masses, and pain or tenderness elicited on light and deep palpation. No hepatomegaly and splenomegaly. Kidneys are not palpable. l. Genitalia Slight enlargement of the Right scrotal sac comparing to the left, slightly firm but with absence of Inflammation. No other deformities noted. Positive transillumination on the scrotal sac. m. Musculoskeletal

No gait and stance abnormalities noted with full range of motions in big and small joints. m. Extremities No gross deformities and edema on upper and lower extremities. Peripheral pulses are regular and full. II. Neurologic Examination a. MMSI Patient is awake, alert, conscious, coherent, and cooperative. He is oriented to places, people, and time and is able to talk fluently with good articulation and vocabulary. He can name objects and with good immediate, recent, and remote memory. b. Cranial Nerves CN I not tested; no complaints of loss of appetite was noted. CN II (GUI, ANO VISUAL ACUITY NYO?); No cuts in visual fields were noted. Both pupils are 3-4mm in diameter, reactive to light with direct and consensual pupillary reflexes. Both eyes have ROR. CN III, IV, VI Primary gaze at center without strabismus. EOMs are full in all directions without complaints of double vision. CN VII Facial features are symmetrical. CN VIII Patient is able to hear spoken words. No lateralization noted with AC>BC. CN IX, X Uvula at midline with intact gag reflex. CN XI Patient is able to shrug shoulders against resistance and full range of motion was observed on left and right SCM muscles. CN XII Togue at midline without atrophy and fasciculations. c. Motor and Sensory Patient has 5/5 motor strength on all extremities and is able to appreciate pain and light touch sensations over dermatomal levels. d. Cerebellar Exam No abnormalities in the gait and stance of patient were observed. He is able to do simultaneous supination and pronation of hands and negative nose to finger, heel to shin, and Rombergs tests. e. Deep Tendon Reflexes Tendons Biceps Triceps Brachioradialis Patellar Ankle Grade +2 +2 +1 +2 +2

PLANNING: Ultrasound to confirm the diagnosis and to rule out other possible cause of the enlargement.. INTERVENTION: Surgical intervention: Hydrocelectomy to remove the hydrocele. Provide prophylactic antibiotic for one week to prevent infection and anti-inflammatory drugs to hasten healing and relieving of pain. Also advice patient and parents to carefully assessed and clean the wounds, and report immediately if signs of infection or any bleeding are observed. Also advised to protect the wound to avoid contamination and to increased intake of vitamin C and proteins to hasten healing process.