Davao Medical School Foundation, Inc

Pediatric Department

Franco, Krista Kamille

Frasco, Jan Mikhail

Gabriel, Norlie

Galigao, Kenneth Anthony

Medicine III

August 26, 2016

Patient Name: T.P. Room/Bed No. 328-2

Date/Time Admitted: August 23, 2016 4:00pm Date/Time Interviewed: August 24, 2016 3:30pm

Informant: Mother Reliability: 75 %

GENERAL DATA

Patient Name: T.P.

Age: 17

Birthday: November 11, 1998

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Address: Bankerohan, Davao City

CHIEF COMPLAINT: Fever, Vomiting

HISTORY OF PRESENT ILLNESS

2 days prior to admission, patient experienced sudden onset of headache with undocumented
fever, took Paracetamol (Saridon) 500 mg, afforded no relief, no consult done.

1 day prior to admission, above symptoms still noted now accompanied with abdominal pain,
nausea and non-bilious, non-projectile postprandial vomiting amounting to approximately 2 cups. Took
Paracetamol 500mg po for the fever. No other associated findings noted, still no consultation done.

16 hours prior to admission, worsening of symptoms noted, now with accompanying body
malaise and retro-orbital pain. Sought consult at a local hospital together with her aunt. Noted to have
moderate grade fever (38.8C); Laboratory tests were done, Urinalysis and CBC Normal, with platelet
count of 162. She was given Paracetamol + Orphenadrine (Norgesic forte) 1 tablet TID, and
Domperidone (Motilium) 1 tablet TID for vomiting.

10 hours prior to admission, fever not relieved now with associated joint pains. Persistence of
findings prompted admission.
PAST MEDICAL HISTORY

Date/Duration/Age Chief Complaint/ Diagnosis/ Hospital/Clinic

Treatment
February 2012: Abdominal Pain and Fever Private Hospital
Admitted for 3 days Diagnosis: Hyperacidity Cotabato City
12 years old Omeprazole 20 mg capsule x 3
days

SURGICAL HISTORY:

She did not undergo any surgery

ALLERGIES:

Patient is allergic to Penicillin, but does not have any food allergies.

OB/GYNE HISTORY:

She had her menarche at the age of 9 regular with a 28 day cycle lasting for 5 days, soaking 4-5
pads per day with associated dysmenorrhea. On the day of interview, patient is currently on her 3rd day
of menstruation and claims that she had soaked only 2 pads for the day.

FAMILY HISTORY:

Her Father is a known hypertensive since the age of 40. No other history of hereditary diseases
in the family.

BIRTH/PREGNANCY HISTORY

She is third among 3 siblings, and her mother was 29 years old when she got pregnant with the
patient. Her first prenatal visit was at 6 weeks AOG, when she tested positive using an OTC Pregnancy
Test Kit. She consulted a Midwife and had complete prenatal visits at a local Brgy. health Center. She
was given Multivitamins 1 capsule OD. No Hepatitis B Vaccine was given. No history of pregnancy
related problems, except that during the third trimester, she had noted an episode of palpitations
without other accompanying symptoms. No family planning method was practiced.

PERINATAL HISTORY:

Her mother is G3P3 (3003), the patient was born via NSVD in a Local Hospital (Cotabato City),
Labor lasted from 3am 10:40 am. The patient had a good cry as claimed by the mother and no
complications of delivery were noted.

POSTNATAL

Immunization schedule at the Barangay Health Center was followed and completed.

She was breastfed for 3 months but shifted to formula feeding using S26 4-5 times a day. Solid
foods were introduced to her at 6months, she was frequently given Cerelac. The mother claims she gave
her vitamins but was unable to recall the brand and name.
 First tooth erupted at 6.5 mos and she was able to sit without support at 8 months. She was
able to walk at 10 mos.

DIET/NUTRITIONAL HISTORY:

Patient is not a picky eater; she frequently cooks their dinner at the boarding house. Diet usually
consists of Rice and 1 viand. Frequently skips breakfast and drinks coffee instead. She loves to drink cola
and can consume around 1-1.5 Liters /day. She claims, cola is her alternative to water.

SOCIAL HISTORY:

She is currently living in a boarding house with her 2 brothers. Her parents are in Cotabato City
and would only visit them once a week, of if their schedule permits, they would travel back home. She is
a sophomore in UIC, taking up Pharmacy. She wants to shift to another course and even apply for the
PMA but her father did not approve of it. She does not have a favorite subject but excels in physical
education and is a volleyball varsity player of their school. She usually hangs out with her friends and
goes home around 8pm after her class. She is a social drinking, claiming to consume 2-3 bottles of beer
and smokes 2 sticks of cigarette at the same time. She also does not use any illicit drugs and spends her
leisure time strolling in malls or sleeping.

ENVIRONMENTAL HISTORY

She lives with her 2 brother in a boarding house in Bankerohan. The building is made of wood
and the 3 of them share a big room at the 2nd floor. The windows do not have screens and they usually
leave it open in the morning. They have their own comfort room and the kitchen and dining area are
shared with the other occupants, but they have their own cooking equipment and utensils. There are
open canals and manholes outside of the boarding house where stagnant water can be found. Tap water
serves as their water source.

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS:
Constitutional symptoms: (-) Weight loss, (-) fever, (-) loss of appetite, (+) weakness
Skin: (-) itchiness, (-) excessive drying and sweating, (-) cyanosis, (-) jaundice, (-) Pallor
Head: (-) dizziness, (-) numbness, (-) vertigo
Eyes: (-) photophobia, (-) blurring of vision, (-) double vision, (+) retro-orbital pain
Ears: (-) earpain, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and sinuses: (-) change in smell, (-) nose bleeding
Neck: (-) pain, (-) limitation of movement
Respiratory: (-) hemoptysis, (-) chest pain, (-) difficulty in breathing
Cardiovascular: (-) syncope, (-) easy fatigability, (-) palpitation, (-) orthopnea
Gastrointestinal: (-) dysphagia, (-) diarrhea, (-) constipation, (+) nausea, (+) vomiting, (+) abdominal
pain
Genitourinary: (-) urinary frequency, (-) dysuria, (-) incontinence , (-) hematuria
Nervous system: (-) numbness, (-) loss of memory, (-) confusion (-) loss of consciousness
Extremities: (+) joints paints, (-) stiffness, (-) numbness, (-) limitation of movement
Hematopoietic: (-) bleeding tendency, (-) pallor, (-) easy bruising, (-) history of transfusion reaction
Endocrine System: (-) intolerance to heat and cold, (-) excessive weight gain or weight loss

PHYSICAL EXAMINATION

General:

She was awake, conscious and coherent. She sits without discomfort and not in respiratory
distress. She was oriented to time, place and person. Stands 5 feet and 2 inches tall and weighs 63 kg
with BMI of 25.2 kg/ m2 (overweight).

Vital Signs

Blood Pressure: 110/ 70 mmHg (Supine)

Cardiac Rate: 86 bpm

Pulse Rate: 85 bpm

Respiratory Rate: 19 cpm

Temperature (Axillary): 38.2 C

Skin:

The patient has generalized fair skin color. The nails are without clubbing and cyanosis. The
patient was warm and dry to touch along with a good skin turgor. No lesions and ecchymosis was
noted.

Head:

Hair is black, equally distributed and well groomed. Scalp without lesions, normocephalic and
without signs of trauma.

Eyes:

Eyebrows are thin, symmetrical and well aligned. Conjunctiva is pink and sclera is white. Pupils
are equally round and reactive to light and accommodation, with 3mm size. Extraocular movement
intact. No lesions, dryness or inflammation were noted

Ear:

Auricle is symmetric in position, aligned with the outer canthus of the eyes. No discharge,
foreign bodies, redness of skin or swelling of the ear canal. There were no signs of irritations or lesions.
Ears are mobile, firm and nontender upon palpation.

Nose and Sinuses:

 Mucosa is pink and septum in the midline. There were no lesions or discharges noted. No
tenderness of frontal and maxillary sinuses upon palpation.

Mouth:

Lips are pink in color, moist and without cracks or lesions. The oral mucosa & gums are pink,
without any lesions. Tongue is pink and at midline. The uvula is positioned at the midline. Tonsils are not
inflamed. Teeth are slightly yellow with good dentition.

Neck:

The trachea is midline and thyroid gland was not palpable. Neck veins not distended. No swollen
or tender lymph nodes noted. There were no adventitious breathe sounds. Normal neck range of
motion noted.

Thorax and Lungs:

Symmetrical lung expansion and no observable masses or lesions noted. No tenderness upon
palpation. Equal tactile fremitus noted. Upon percussion, resonance is noted with no dullness. Clear
breath sounds on both lung fields upon auscultation.

Cardiovascular:

Jugular veins are not distended. Carotid pulsations noted on both sides. There were no thrills,
heaves, lifts noted. No heart sound change on the lateral ribs. Point of maximum impulse heard on the
5th intercostal space midclavicular line. Heart rate is at 85 bpm with a normal rhythm. No abnormal
heart sounds or murmurs heard.

Breast

Unable to assess

Abdomen

No lesions or post operative scars noted. Normoactive bowel sounds with 15 clicks per minute.
Pain upon palpation at epigastic region with a painscale of 4/10. Liver edge palpable 2-3 fingerbreadths
below the right subcostal margin.

Genitalia:

Unable to assess

Rectal:

Unable to assess

Extremities:

Both upper and lower extremities symmetrical in shape. No observable deformed joints, lesions
and ulceration. Extremities are warm and without any edema. No varicosities or stasis changes. Axillary,
brachial, radial, posterior tibial and dorsalis pedis pulses are 2+ and symmetric. No tenderness noted on
full range of motion.

Mental Status:

She is awake and conscious, GCS 15. She has a relaxed pace, capable of voluntary full range of
motion with firm movements. She appears well groomed, and has appropriate facial expressions. She is
able to communicate well with others with an appropriate affect. She talks with intermediate rate of
speech and minimal loudness. She is conscious and oriented to person, date, time and place and is able
to remember some events in the past.

Cranial Nerves:

I- Patient was able to smell accordingly

II- Patient had equal visual fields.

III, IV, VI- Pupils are equally and briskly reactive to light and accommodation, isochoric,
measuring 3mm in diameter and with an intact extraocular movements.

V- Patient was able to clench teeth and feel soft touches on her face; Intact corneal
reflex

VII- Patient was able to project facial expressions without difficulty

VIII- Patient able to hear whispered voice; AC> BC; lateralization of sound on both ears

IX, X- Patient was able to swallow and speak without difficulty

XI- Patient was able to shrug shoulder against resistance with equal strength

XII- Patient was able to move tongue freely in all directions

Gait & Stance:

Patients gait and stance were not assessed

Motor:

Good muscle bulk and tone. Strength 5/5 throughout.

Sensory:

Light touch, pain, and vibration intact

Reflexes:

2+ and symmetric

IMPRESSION:

Dengue Fever with Warning Signs

 Salient features:

Fever- 38.9 degrees Celsius Myalgia

Abdominal pain Arthralgia
Headache Menstruation (3rd day)
Nausea Hepatomegaly
Vomiting Thrombocytopenia
Fatigue
Rainy season

DIFFERENTIAL DIAGNOSIS

1. ENTERIC FEVER/TYPHOID FEVER

- Typhoid fever is an acute illness associated with fever caused by

theSalmonella typhi bacteria. It can also be caused by Salmonellaparatyphi, a related
bacterium that usually causes a less severe illness. The bacteria are deposited in water
or food by a human carrier and are then spread to other people in the area.

RULE IN RULE OUT

Fever (-) gastroenteritis
Abdominal pain (-) constipation
Hepatomegaly (-) rose spots
Headache (-) coated tongue
Nausea (-) relative bradycardia
Vomiting
Thrombocytopenia
Arthralgia
Malaise
2. CHIKUNGUNYA

- Chikungunya is a viral disease transmitted to humans by infected mosquitoes. It causes

fever and severe joint pain. Other symptoms include muscle pain, headache, nausea, fatigue
and rash. Joint pain is often debilitating and can vary in duration. The disease shares some
clinical signs with dengue, and can be misdiagnosed in areas where dengue is common.
There is no cure for the disease. Treatment is focused on relieving the symptoms.

RULE IN RULE OUT

Fever (-) severe joint pain, prolonged.
Arthralgia (-) conjunctival infection
Myalgia (-)maculopapular rash
Thrombocytopenia
 Abdominal pain
Headache
Nausea

3. MALARIA

- Malaria is a life-threatening disease caused by parasites that are transmitted to people

through the bites of infected female Anopheles mosquitoes. It is the most common and most
important parasitic disease in the world.

RULE IN RULE OUT

Headache (-) Paroxysm
Fatigue (-) exposure to malaria endemic areas
Abdominal discomfort (-) orthostatic hypotension
Myalgia (-) temp of above 40 degrees Celsius
Fever (-) tachycardia
Nausea (-) mild jaundice
Vomiting (-)chest pain

4. LEPTOSPIROSIS

Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of
the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may
be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.
Without treatment, Leptospirosis can lead to kidney damage, meningitis (inflammation of the
membrane around the brain and spinal cord), liver failure, respiratory distress, and even death.

RULE IN RULE OUT

Fever Not exposed to contaminated waters like flood
and no contact with animal urine or blood.
Headache (-) jaundice
Myalgia (-)rashes
Abdominal pain (-)conjunctival suffusion
Hepatomegaly

Final Diagnosis:

Dengue Fever with Warning Signs

Dengue fever is a benign syndrome caused by several arthropod-borne viruses and is characterized by
biphasic fever, myalgia or arthralgia, rash, leucopenia, and lymphadenopathy.
RULE IN

Fever
Nausea
Vomiting
Aches and pains
Abdominal pain
Persistent vomiting
Liver enlargement (2-3 fingerbreadths below the right subcostal margin
Thrombocytopenia
Occurs more often in rainy seasons
Retro-orbital pain

DIAGNOSIS

Complete blood count: leucopenia, thrombocytopenia, elevated hematocrit

Dengue IgM and IgG (ELISA): IgM- detected by day 5 of illness; IgG- detects past dengue
infection
NS1 Antigen (rapid) Test: aids in the screening and diagnosis as early as 1-day post onset of
symptoms
Tourniquet test: considered positive if > or = to 20 petechiae per square inch, 1.5 inches from
the volar aspect of the antecubital fossa

MANAGEMENT

Encourage OFI if tolerated

IVF
Monitoring of VS q1-4 hrs
Hct at baseline and q6-12 hrs