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Pediatric Clinical Correlation Chronic Case

This clinical case details the evaluation of Junsen Barcas Vitug, a 16-year-old male admitted on February 11, 2011, presenting with swelling in the right thigh. His medical history includes primary complex, intracerebral hemorrhage, and family predispositions to hypertension and hemophilia. Developmental and behavioral assessments highlight good academic performance and healthy family relationships. The case underscores the importance of thorough family history review and complete physical examination in diagnosing chronic conditions in pediatric patients.

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Pediatric Clinical Correlation Chronic Case

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Presentation Transcript

  1. Pediatric Clinical CorrelationChronic Case Group 3 (Lim, Harold- Lipana, Kirk)

  2. General Data • Date of Admission: February 11, 2011 • Name: Vitug, JunsenBarcas • Age: 16 • Sex: M • Birthdate: December 24,1994 • Address: Blk. 27, Lot 10, Palmera Spring II, Novaliches, Caloocan City • Nationality: Filipino • Religion: Roman Catholic • Informant: Father and Patient • Reliability: 80%

  3. Chief Complaint “namamagaangkananghita” ( swelling of the right thigh )

  4. History of Present Illness

  5. Immunization History • Completed EPI from health center until 9 months of age • Past Medical History • Primary complex(treated)- 6 months of HRZE • Varicella- 9 years old • Intracerebralhemorrhage: 2008 (factor VIII infusion); resolved • Family History: • Hypertension -Grandparents • Hemophilia A – Both siblings • Brain tumor- Maternal grandmother • Prostate cancer- Maternal grandfather

  6. Developmental/ Behavioral History • Home: Second of 3 siblings, lives with his parents and brothers in Caloocan • Education: currently 3rd year High School Student in Bagumbong High School in Caloocan; average academic performance • Eating Behavior: good appetite, no specific food preference, five basic food groups present in daily meals • Abuse: no reported sexual abuse or observed signs of physical abuse • Activities: goes out with friends, stays home often • Drugs: denies illicit drug use, non alcoholic beverage drinker, non smoker • Sexual: denies sexual contact/activity; has not had romantic relationships • Safety: wears seatbelt when riding cars; commutes often • Suicidal ideations: no suicidal ideations/attempts • Family: good interpersonal relationships with family members • Image: good self esteem/desires opposite sex • Recreation: goes to malls with family, use of internet, texts often • Spiritual: regularly goes to Sunday mass • Threats/Violence: no imposed harm to self or others; no reported threats

  7. Socioeconomic/Environmental profile • Patient lives in a 1-storey house with one bedroom with his immediate family. • Source of drinking water from a water station and bathing water is from NAWASA. • Garbage is collected once a week. • The family owns a pet dog. • Father is a smoker.

  8. Review of Systems

  9. Physical Examination

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