PHILIPPINE CHILDRENS MEDICAL CENTER

Quezon Avenue, Quezon City

General Data:
The patient is D.A., a 10 year old female, Filipino, Iglesia ni Cristo from Angono, Rizal, who was
admitted for the first time in our institution last May 19, 2014.
Informant: Mother
Reliability: 90%
Chief Complaint: fever
History of Present Illness:
Diagnosed case of CHD, VSD since 1 year old initially maintained on Lanoxin but was lost to follow
up since 3 years prior wherein medications were also discontinued.
Three weeks prior to admission, the patient presented with abdominal pain, hematuria and facial
edema. Consult was done at a local hospital where the patient was treated as a case of post-streptococcal
glomerulonephritis and was given Ampicillin-Sulbactam. KUB-ultrasound revealed renal parenchymal
disease and cystitis. Urinalysis revealed too numerous to count RBCs hence the patient was referred to a
tertiary hospital.
Two weeks prior to admission, the patient was transferred to a tertiary hospital. On physical
examination, the patient was noted to have dynamic precordium and continuous murmur associated with
abdominal pain and fever. Further work up were done as follows: CBC showed Hgb 89, hct 26.6, WBC 14,
seg 62%, lym 22%. Other ancillary diagnostics showed Crea 13, BUN 13, CRP 340, ESR 145, ASO 683, C3
116. 2D echo showed vegetation at aortic valve with minimal pleural effusion, bilateral, VSD
perimembranous, AR severe, MR mild, TR mild. Chest xray showed biventricular cardiomegaly. Blood CS in
2 sites showed no growth after 7 days. The working impression at the time was infective endocarditis, CHD
VSD perimembranous, AR severe, MR mild, TR mild. The patient was then started on cardiac meds:
Furosemide (0.5mkdose) qD, Enalapril (0.5mkdose) q12 and Digoxin (0.004)ukdose q12. Due to financial
constraints, patient opted transfer to PCMC for further management.
Review of Systems:
General: No pallor, no jaundice, good appetite
Neurologic: No dizziness, no seizures
Respiratory: No cough, no colds, no difficulty of breathing
Cardiovascular: No chest pain, (+) occasional palpitations
Gastro/Nutrition: Good appetite, no abdominal pain, no changes in bowel movement, no dysphagia
Genitourinary: No changes in frequency of urination, no dysuria
Musculoskeletal: No muscle pains, no atrophy, no nail changes
Hematologic: No bleeding, no easy bruisability
Birth and Maternal History:
The patient was born to a 30 year old G2P2 (2002), non-smoker, non-alcoholic beverage drinker with
regular prenatal check-up at a local health center since 2 months age of gestation. The mother had regular
intake of multivitamins, folic acid and ferrous sulfate. The mother had no maternal illness, no exposure to
radiation, teratogen or viral exanthem during pregnancy.
The patient was delivered full term via normal delivery at a lying in clinic attended by a midwife. The
patient had good cry and activity. There were no fetomaternal complications. Newborn screening was done
showing normal results. Hearing screening was done with normal results.
Nutritional History:
The patient was mixed feeding since birth. Complementary feeding was initiated at 6 months. Table
food was introduced at 1 year old. Currently, the patient is not a picky eater.

Immunization History:
The patient received immunizations from the local health center, with no adverse reactions noted.
The patient had 1 dose of BCG, 3 doses of Hepatitis B, 3 doses of DPT, 3 doses of OPV and 1 dose of
measles. No booster doses given.
Family History

(+) Hypertensionboth sides

(-) Diabetes
(-) Asthma
(-) Malignancies
(-) Blood dyscrasias
(-) PTB

40

41

12

10

Past Medical History:

The patient had no history of any medical condition or prior hospitalizations aside from the ones
related to the present condition. The patient also had no previous surgeries.
Personal and Social History:
The patient lives with his paternal grandmother and father in a well-lit, well-ventilated house. He has
6 household members. Drinking water is mineral. There are no pets in the household. There is no cigarette
smoke exposure within the household. Garbage is collected twice daily. The patient also had no history of
recent travel.
PHYSICAL EXAMINATION
General: Conscious, coherent, wheelchair-borne, not in cardiorespiratory distress
Anthropometrics: Weight 26.5 kgs Height 128 cm
Vital signs: HR 98 bpm
RR 23 cpm BP 100/70 mmHg T 37.3 oC O2 saturations 98% (room air)
Skin: No note of skin lesions
HEENT: Anicteric sclerae, pink palpebral conjunctivae, no eye discharge, no bleeding, no corneal opacities
No nasal discharge, nasal septum is midline
Intact tympanic membrane, AU
Non-hyperemic posterior pharyngeal wall
No palpable lymph nodes
Chest and Lungs: Symmetric chest expansion, no retractions, good air entry, clear breath sounds
Cardiovascular: Dynamic precordium, (+)heave, (+)thrills, PMI at 5th ICS, left midclavicular line. Normal heart
rate, regular rhythm, (+) Gr 5/6 systolic murmur heard best at 3 rd-4th ICS left parasternal border radiating to
the axilla
Abdomen: Globular abdomen, AC 56cm, normoactive bowel sounds, tympanitic on all quadrants
Soft, no masses/ tenderness
Extremities: No gross deformities, No joint swelling/ tenderness/edema. Pulses are full and equal. CRT < 2
seconds.
Neurologic:
Sensorium: Awake, can follow commands
Cranial Nerves:
I NA
II 2-3 mm ERTL, visual acuity: no light perception, OU, fundoscopy: no papilledema, no
retinal hemorrhages seen
III, IV, VI full and intact EOMS
V good masseter tone
VII no facial asymmetry

VIII intact gross hearing

IX, X intact gag reflex
XI good shoulder shrug
XII no tongue deviation
Good muscle tone, MMT: grade 5/5 on upper extremities, grade 5/5 on lower extremities
100% sensation on all extremities
Reflexes: +2 on all extremities, (-) Babinski
(-) clonus
(-) nuchal rigidity

WORKING IMPRESSION:
t/c Infective Endocarditis
COURSE IN THE WARDS:
Upon admission, the patient was maintained on heplock and diet for age. He was started on intravenous
Penicillin G 200,000 IU/kg/d and Gentamycin(5mkd) qD. Furosemide (0.5mkdose) qD, Enalapril (0.5mkdose)
q12 and Digoxin (0.004)ukdose q12 were continued. He was subsequently referred to Cardiology and
Infectious Disease services. Initial CBC showed anemia with Hgb 89, hct 0.26 hence packed RBC was
transfused. 2D echo was repeated showing vegetation at the aortic valve (Endocarditis), CHD, VSD,
Perimembranous with AR severe, MR moderate. The plan during this time was to complete Penicillin G for
28 days then repeat 2d echo. After 16 days of admission, the patient was eventually sent home for
continuation of Penicillin G infusion at a nearby clinic. Take home medications were Penicillin G, Enalapril,
Lanoxin and Furosemide. Patient was advised close follow-up with our institution.
LABORATORY RESULTS
CBC
Hgb
Hct
WBC
Seg
Lympho
Platelet Count

2nd hospital day

89
0.26
10.6
0.68
0.23
631

Blood Chem
Sodium
Potassium
Chloride
Calcium

5th hospital day

105
0.30
11
0.34
0.34
587

7th hospital day

134 mmol/L
4.5 mmol/L
92 mmol/L
2.36 mmol/L

ESR: 134 (13x elevated)

ASO: 1600 IU/mL (8x elevated)
CRP: 12 mg/L (2x elevated)
Blood CS (2 sites): no growth after 5 days
Chest X-ray:
Calcified granuloma, right upper lobe
Subsegmental atelectasis, left lower lung
Biventricular cardiomegaly
Minimal pleural effusion (bilateral)
2D echo:
Vegetation at Aortic Valve (Endocarditis)
CHD, VSD, Perimembranous with AR severe, MR moderate
KUB-ultrasound: Consider renal parenchymal disease/ pyelonephritis, suggest correlation with laboratory
parameters; cystitis; minimal peritoneal fluid in the pelvic area, bilateral pleural effusion