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Submitted By:

Francis Martin T. Planta

Clinical Clerk 2016-2017
University of St La Salle
This is a case of patient P.M., a 9 months old female, Filipino, Catholic, from Ilog, Negros Occidental, with
a diagnosis of Neuroblastoma.

Patient is born term to a G2P2 (2003) mother with a twin, delivered via normal spontaneous
delivery at a local district hospital without complications. With birth weight of 2.5kg, birth
length of 44 cms and good apgar score of 9, 10. Noted good cry and good suck, no jaundice.
At 5 months old, patients folks noted a slowly growing mass at the lower back associated with
weakness of movement and eventually progressing to immobility of the lower extremities. Folks sought
consult with a private physician, and was given unrecalled medications. Patient was also referred to a
specialist which advised CT scan of the whole abdomen but was not able to comply due to financial

At 7 months old, there was persistence of the growing mass and no resolution of the immobility. They
again sought consult and was then admitted under the department of surgery. CT of the whole abdomen
was done which showed retroperitoneal mass lesion with invasion into adjacent spinal column and
paraspinal muscles with possible involvement of the spinal cord. Malignancy primarily considered.
Biopsy of the mass was also done revealing an impression of small round cell tumor favoring

Due to the proximity of the lesion to the spinal cord, surgery became an unlikely option. Patient was
advised and underwent chemotherapy with cyclophosphamide, etoposide, and GCSF 1 month prior to

Patient was scheduled for 2nd cycle of chemotherapy and was then admitted.

Review of Systems:

General: No weight loss or fever. Non irritable.

Skin: No itchiness or rashes
Head: No complaints of headache, dizziness and lightheadedness
Eyes: No complaints of pain, redness, excessive tearing
Ears: No complaints difficulty in hearing or discharges
Nose: No complains of colds, nasal stuffiness or bleeding
Throat: No complaints of poor suck or irritable cry
Neck: No complaints of stiffness, lumps and pain
Respiratory: No complains of difficulty breathing or coughing
Gastrointestinal: No complaints of diarrhea, constipation, or poor feeding
Peripheral vascular: no complaints of edema
Genitourinary: no complaints of vaginal discharges, hematuria or oliguria
Musculoskeletal: no complaints of muscle stiffness, pain and tenderness
Neurologic: no reports of seizures or tremors
Hematologic: no complaints of easy bruising or bleeding
Endocrine: no complaints of excessive thirst or hunger, cold and hot intolerance
Past Medical History
Prenatal History:
Patients mother started monthly prenatal check-ups at 3 months age of gestation at a
local health center. Maintained on multivitamins with iron and folic acid. No maternal illness
noted during the course of pregnancy.
Birth History:
Patient is born term to a G2P2 (2003) mother with a twin, delivered via normal
spontaneous delivery at a local district hospital without complications. With birth weight of
2.5kg, birth length of 44 cms and good apgar score of 9, 10. Noted good cry and good suck, no
Nutritional History:
Patient is exclusively breastfed since birth and feeds 8-10 times a day with good suck.
Multivitamins given once a day and has not yet started complimentary feedings.
Immunization History:
Patient has already received 1 dose of BCG and Hep B, 3 doses of DTP, OPV, and PCV
Family History:
Personal and Social History:
Patient lives in a concrete house near the sea. The family uses pour flush toilet and uses
mineral water to drink.
Physical Examination:

General Survey: Patient is awake and active. No signs of distress noted throughout the interview.
Patient is dressed appropriately for the environment.
Vital Signs:
Ht: 66 cms BSA: 0.33 CR: 119 bpm Temp: 36.2C
Wt: 6.3kg BMI: 14.5 RR: 23 cpm
The skull is normocephalic and atraumatic. No deformities nor injuries of the scalp. Scalp has no
discolorations, lesions or scaling. Anicteric sclera with pinkish conjunctiva bilaterally. Both
pupils are equally round and directly and consensually reactive to light and can accommodate.
Ears symmetrical without discharges. Nose symmetrical, no septal deviation or discharges. Oral
mucosa and gingiva pink in color. No lesions noted.

Thorax and Lungs:

Thorax is symmetrical with good expiration. Symmetric rise and fall of chest. Palpation revealed
no masses or areas of tenderness. Vesicular breath sounds in majority of the areas in both
anterior and posterior thorax. No adventitious breath sounds. No bronchophony, egophony and
whispered pectoriloquy were noted.

Breast and Axilla

Breast is symmetrical with no thickening of the skin. Nipples without discharges. No tenderness
upon palpation of breast and axilla. Lymph nodes not enlarged.

Inspection revealed PMI located 12cm lateral to the midsternal line with irregular timing. No
thrills were felt. No bruits or thrills also in the carotid arteries. Cardiac dullness heard in the left
3rd, 4th and 5th ICS. Grade 2 murmurs were heard over the 3-5th intercostal space on the lateral
sternal border with increasing intensity over the apex. Jugular venous pressure measured 4 cm
above the sternal angle taken with head elevated 30 degrees.
The abdomen was symmetric, uniformly brown in color, no areas of redness or swelling was
note. Bowel sounds with a frequency of 16/minutes were heard. No bruits or friction rubs heard.
No pain on both light and deep palpation. No masses were felt. Liver span measures 6 cm
midclavicular line and 4 cm midsternal line. Smooth liver edges and no pain during palpation.
Spleen and kidneys were not appreciated during palpation. Negative for splenic percussion sign
and negative costovertebral pain. No shifting dullness nor fluid wave.

Peripheral Vascular:
No varicosities noted on both upper and lower extremities. Extremities are warm to touch
without pitting edema and no palpable epitrochlear nodes. Color of the nail beds is pinkish and
nails without clubbing or cyanosis.
Pulses: Full
The patient's Temporomandibular joint is intact, it is symmetric, no atrophy, tenderness or
swelling in the muscles of mastication. The patient was able to exhibit a full range of motion in
the TMJ. Symmetric shoulder, elbow, wrist and hands bilaterally. No tenderness, swelling,
atrophy of joints bilaterally. Full range of active and passive motion on shoulder, elbow, wrist
and hands of the patient. The patient was able to exhibit a full range of motion in the spinal
column and hip joint. The patients knees were symmetric, no swelling or effusion. MCL, ACL,
PCL and LCL were all intact. The patient was able to flex and extend his knees without
restrictions and tenderness. No tenderness and were able to exhibit full range active and passive
of motion on the ankle.

Mental status:
Patient sitting in bed, alert, relaxed, and cooperative. Oriented to time person place
Cranial Nerves:
I intact sense of smell,
II visual acuity intact; visual fields full;
III, IV, VI extra-ocular movements intact;
V motor-temporal and masseter strength intact, sensory-corneal reflexes present;
VII facial movements intact, sensory-sense of taste intact;
VIII-hearing intact; negative lateralization
IX, X-gag intact;
XI-strength of sternomastoid and trapezius muscles 5/5;
XII-tongue midline.
Motor System: Good muscle bulk, tone, and strength.
Cerebellar: Rapid alternating movements of the hands, finger to nose intact.
Sensory System: Pinprick, light touch, position, and vibration intact.

Reflexes: 2+ all