PEDIA CASE FOR GROUP 2

Date of Admission: March 15, 2021 @ 10am

Progress in the ER (Day 1): You are assigned to JXDN, 12 y/o, male, a Roman Catholic and
lives in P-3 Poblacion, Valencia City Bukidnon, accompanied by his father. Pt. complaints of fever
and vomiting.

History of present illness:

Five days PTA - intermittent, undocumented fever; no vomiting, no cough and colds, and no loose
stools noted; Two days PTA, still no cough and colds, no vomiting and no loose stools, fever
persisted, (+) abdominal pain in the epigastric area; consult sought @ Valencia Medical Center;
CBC (Hgb: 112, Hct: 0.27, WBC: 3.7, Platelet: 125); Initial Diagnosis: Urinary Tract infection –
prescribed Cefalexin (unrecalled dose) and paracetamol 250mg before discharge. One day PTA,
fever and epigastric pain still persisted, now with vomiting of three episodes (1cc/episode); still
with no cough and colds, no loose stools. On the day of admission fever, epigastric pain and
vomiting were persistent which prompted consult. CBC was ordered at the AMCV (Hgb: 146, Hct:
43, WBC: 5.2, Platelet: 97), advised admission.

Past Medical History:

 No history of Asthma, allergies, and primary complex

 No known allergies to food and medication

Family History:
 No history of malignancies, DM, HTN, Atopy/Allergies, Bronchial Asthma, TB in the
Paternal side of the family
 Patient’s mother is hypertensive and the maternal grandmother was an Ovarian Cancer
survivor
 There are no other known heredo-familial illnesses

Personal History:
Birth and Maternal History
o Preterm ( unrecalled AOG) to a 25 year old G3P2 (0212)
o Non-smoker, non-drinker, regular prenatal check-ups starting 1 month
o Caesarean Section by an OB-GYN in a hospital
o Birth weight and heaight was unrecalled
o APGAR: good cry after delivery
o Mother took unrecalled Multivitamins
o Maternal complications: pre-eclamptic during delivery
o Vitamin K & eye care
o Newborn screening done
o Baby noted to jaundiced – resolved after one week

Nutritional History
o Breastfeeding: birth until 1.5 years
o Formula (Nestogen, Bona) until 6 years old
o Complementary feeding at 5 months
 o 24 hour diet recall:
- Rice and adobo for breakfast
- Rice and pork sinigang for lunch
- Fried fish and monggo for dinner
- Morning snack was bread and milk
 Preference for chicken, pork, beef and squash and regularly consumes softdrinks and junk
food for snacks

Immunization History

o BCG (1), DPT (3), OPV (3), HiB (3), HepB (4) MMR (2), measles (1)
o Rotavirus (0), Pneumococcal (0), Influenza (0) Varicella (0), Hep A (0) and
Typhoid (0)
o He has not yet had boosters for Hep B, DTaP and MMR

Hospitalization History:

 2012 for Acute Gastroenteritis

Surgical History:

 2011 for incision and drainage of a Neck abscess

DEVELOPMENTAL HISTORY:

 Can stand on his own at 10 months, walk up stairs alone at 2yrs; Makes circular strokes
at 2; Knows name and sex, most of speech intelligible to strangers at 3yrs; Parallel play
and helps in dressing at 3 yrs; at par with age, with no noted delay in gross motor, fine
adaptive, social and language developmental milestones.

 Home life is happy; Parents provide for the needs of the family; Patient expressed love
and respect for the parents and his sibling. Occasional disciplinary spanking; Rules are
fairly strict especially in academics; Parents can be relied upon when having a problem;
No recent major changes in the family;
 The child is in grade 6 elementary, a consistent honor student and is currently top 1 of
his class. He was not bullied by classmates or other children in the community.
 Preference for chicken, pork, beef and squash and regularly consumes softdrinks and
junk food for snacks; Especially likes fried chicken and hamburgers; No diets; Sees self
as thin.
 Likes to play basketball and tumbang preso with friends and classmates; Spends about 2
hours browsing social media during holidays and weekends. None during school days
TV: 1 hour every day; has a male best friend in his class.
 Has no friends who smoke, drink or tried drugs; Has not tried drugs himself: fears
parents
 Interested in opposite sex, but has no crushes or girlfriends; No forced or uncomfortable
sexual experiences.
 Has no suicidal ideations; Does not hurt himself; Financial situation of family makes him
sad; Sleeps well; Vents anger or sadness through crying
 Not a member of a gang or fraternity; Accompanied by the mother or father going to
and from school
  Roman Catholic; Believes in God; Prays at night but does not go to church regularly

PHYSICAL EXAMINATION:

 General Appearance - Awake, alert, and not in cardiorespiratory distress. Weak-looking;

Weight: 34kg; Height: 140cm; BMI 17.3
 BP: 90/60 HR: 120 bpm RR: 24 bpm T: 38.6 C – March 15, 2021 @ 10am
 BP: 90/60 HR: 69 bpm RR: 12 bpm T: 36.5 C – March 16, 2021 @ 10am

PHYSICAL ASSESSMENT:

Normocephalic, flushed face, No CLADS, No neck vein engorgement. No lesions in scalp;

Anicteric sclerae, Pink palpebral conjunctivae, No eye discharge, No periorbital edema, No
matting of eyelashes, Eyes are briskly reactive to light, (+) Red orange reflex; Ears are
symmetric. Ear canal is non-hyperemic and tympanic membrane is not bulging. No tragal
tenderness. Visible cone of light bilaterally, with brownish retained cerumen partially
occluding the ear canals bilaterally; Nasal Bridge is flat, no alar flaring, nasal septum is
midline, and turbinates are pink with no watery nasal discharge; Dry lips, moist oral
mucosa, hyperemic buccal mucosa and pharyngeal walls. No tonsilar enlargement. Dental
carries present. No gingival and mucosal lesions; Adynamic precordium, No heaves no
thrills, Regular cardiac rate and rhythm, Distinct heart sounds s1>s2 at the base, Apex
beat at the 4th ICS MCL, No murmurs appreciated; Symmetric chest expansion, No
retractions, No lesions or masses. Clear breath sounds; No lesions and obvious spinal
deformities; Flat abdomen, no distention, no scars, no masses, normoactive bowel sounds
and tympanitic on all quadrants, with epigastric tenderness (pain scale= 5/10) but no
organomegaly on palpation; Negative tourniquet test, no obvious deformities, no lesions,
no clubbing, and no cyanosis. Full range motion of upper and lower extremities on active
and passive motion; No rashes, no lesions, no jaundice no cyanosis, good skin turgor.
CRT<2secs; Glasgow Coma Scale: 15, Cranial Nerves testing not done.

DOCTOR’S ORDER

Date and Time Progress notes Doctor’s Order

March 15, 2021 @  Pls. admit pt. under the service of Dr.
10 am Wt: 34 kg Macarat.
 Secure consent to care
- Febrile – 38.6 C  DIET: DAT but no dark colored food
- epigastric pain and drinks
- vomiting  Bed rest and increase fluid intake
 LABS: CBC, then repeat after 6 hours
 IVF: PNSS 1L and regulate to 20 gtts/hr
CBC  MEDS:
Hgb: 146 1. ORS (200 cc distilled H2O + 1
Hct: 43 sachet ORS) to consume slowly per
WBC: 5.2 orem
Platelet: 97 2. Paracetamol 250 mg 1 cap Q4Hr
PRN for fever
 Date and Time Progress notes Doctor’s Order
 Please refer if w/ persistent vomiting
 VS q4 with hydration status
 BP – q30 mins
 Please refer if BP is 80/60 below
 I & O q shift
 Pls. update Dr. Macarat

3:00pm CBC  2nd bottle PNSS 1L regulate to

Hgb: 152 20 gtts/hr until consumed
Hct: 45
WBC: 5.6
Platelet: 80
March 16, 2021 @  Repeat CBC, possible discharge if
6am platelet is > or = to normal.

Dr. Macarat

Progress in the Ward (Day 2): Pt. is asleep, comfortable, afebrile with normal pulse rate and
rhythm; equal chest expansion with clear breath sounds; warm extremities with full equal pulses.
Possible discharge if platelet count is increasing.

LABORATORY RESULTS

March 15, 2021 @ 9:45am

COMPLETE BLOOD COUNT

EXAMINATION RESULT UNITS NORMAL VALUES
Hemoglobin 146 g/L 140-180
Hematocrit 43 % 0.40-0.48
Red blood Cell 4.68 10^12/L 4.5-5.0
MCH 21.8 pg 28-33
MCV 70.7 fl 82-98
MCHC 30.9 g/L 33-36
White blood cell 5.2 10^9/L 4.8-10.8

DIFFERENTIAL COUNT
- Neutrophil 55 % 40-70
- Lymphocyte 35 % 19-48
- Monocyte 7 % 3-9
- Eosinophil 9 % 2-8
- Basophil 1 % 0-0.5
- Hematocrit 0.33 % 0.40-0.48
- Platelet count 97 10^9/L 150-400
March 16, 2021 @ 3:00pm

COMPLETE BLOOD COUNT

EXAMINATION RESULT UNITS NORMAL VALUES
Hemoglobin 152 g/L 140-180
Hematocrit 45 % 0.40-0.48
Red blood Cell 10^12/L 4.5-5.0
MCH pg 28-33
MCV fl 82-98
MCHC g/L 33-36
White blood cell 5.9 10^9/L 4.8-10.8

DIFFERENTIAL COUNT
- Neutrophil % 40-70
- Lymphocyte % 19-48
- Monocyte % 3-9
- Eosinophil % 2-8
- Basophil % 0-0.5
- Platelet count 80 10^9/L 150-400

March 17, 2021 @ 6am

COMPLETE BLOOD COUNT

EXAMINATION RESULT UNITS NORMAL VALUES
Hemoglobin 157 g/L 140-180
Hematocrit 40 % 0.40-0.48
Red blood Cell 10^12/L 4.5-5.0
MCH pg 28-33
MCV fl 82-98
MCHC g/L 33-36
White blood cell 5.0 10^9/L 4.8-10.8

DIFFERENTIAL COUNT
- Neutrophil % 40-70
- Lymphocyte % 19-48
- Monocyte % 3-9
- Eosinophil % 2-8
- Basophil % 0-0.5
- Platelet count 150 10^9/L 150-400

After five days of complete treatment, pt.’s condition is improved with a final diagnosis of
Dengue Fever, Grade I.