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Date and time of history: 13 April 2015
Source of the history: Mother
Previously known to be a very active, sensitive, playful and happy child, he was noted to
have episodes of being suddenly quiet and he would made gesture of suddenly banging his fists
whenever his condition was being discussed and cover his ears. He was noted to cry at night
more often, refused to do self-care such as brushing of the teeth and taking a bath, changing the
patch of his eye and application of the eye ointment become daily struggle, She tries to separate
him from his sisters and she tends to give him everything he wants like toys as verbalized by
mother
6 weeks prior to admission, patients mother observed to have a lump on left upper eyelid
which rapidly progressed in size with deviation of left eyeball downward, symptoms rapidly
progressed which prompted consultation to optha on March 21, 2015 at Asian Hospital, biopsy
of the orbital mass was done which revealed Rhabdomyosarcoma, currently admitted for staging
and 1st course of chemotherapy.
REVIEW OF SYSTEMS
General
Skin
Denies rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails
and color/ sizes of moles
Neck
Denies pain, stiffness in the neck
Breast
Denies pain, discomfort, nipple discharge,
Respiratory
Denies dyspnea, cough
Cardiovascular
Denies chest pain, palpitation, edema
Gastrointestinal
Denies difficulty swallowing, heart burn, abdominal pain
Last bowel movement- 8 April 2015
Picky eater, decreased appetite
Peripheral Vascular
Denies leg cramps, swelling with redness or tenderness
Urinary
Denies changes in pattern of urination, flank pain
(+) bedwetting
Male reproductive
Denies discharge from or sores on the penis, scrotal, swelling
Musculoskeletal
Denies muscle or joint pain, stiffness, backache
Psychobiologic
Become moody during dressing
Neurological
Denies fainting, blackouts, seizures, paralysis, numbness, tingling, tremors
Hematologic/ immunologic
Does not experience easy bruising or bleeding
Endocrine
Denies excessive sweating, excessive thirst or hunger
PHYSICAL ASSESSMENT
General survey
Sitting on bed with his mother, preferred to keep his eyes close, speech was non-
spontaneous,
Weight: 16kg
Vital signs: Temperature: 36.5C, Heart rate: 100bpm, Respiratory rate: 22cpm,
Pain: 0/10
Skin
Uniform in color, no presence of any foul odor
Hair
Evenly distributed, no signs of infestation observed
Nails
Smooth, intact with the epidermis, return to usual color in less than 3 sec
Head
Normocephalic, and symmetrical
Eyes
Right eye- no swelling, redness, discharge
Left eye- (+) eye patch, dry and intact
Ears
Auricles are symmetrical, aligned with the outer canthus of eye
Mobile, firm and not tender, was able to hear ticking sound in both ears
Nose
Appears symmetric, straight and uniform in color, no presence of discharge
No tenderness and lesions
Mouth
Lips are dry, symmetric, was able to purse his lips when asked
Pinkish in color of gums, buccal mucosa
Tongue is centrally positioned
Neck
Head movement with no discomfort, no palpable lumps
Abdomen
Uniform in color, symmetric contour,
Extremities
Symmetrical in size and length, no tenderness, swelling, coordinated movements.