Case 1

Date and time of interview: 7/28/2020

Source of Information: Patient

Reliability: 95%

Referral: None

S.M, 23 year old male, single, Filipino, Roman catholic from Brgy. Pawing Palo Leyte was admitted on
7/26, 2020 at 5pm due to fever and tea-colored urine.

History of Present Illness

5 days prior to admission patient developed recurrent moderate to high-grade fever associated with
myalgia and headache. Took Paracetamol 500mg 1 tablet for fever affording temporary relief. This was
later associated with epigastric pain associated with nausea and vomiting.

1 day prior to admission, he noted his urine to be dark yellow in color and decreasing in volume
prompting admission.

Past Medical History

 Childhood illness: (+) dengue at 7 year old admitted at EVRMC transfused with 4 U platelet
concentrate
(+) mumps, measles and chicken pox (date.age unrecalled)
 Adult illness: 2017- diagnosed with UTI treated with unrecalled antibiotic
Negates other comorbidity
 Surgical operations: None
 Allergies: No allergy to food and medication

Family history:

Parents still alive and well.

2nd in a brood of 5. All siblings apparently well.

Negates any heredofamilial disease.

Psychosocial History:

Patient is a high school graduate currently working as a pedicab driver earning Php 300-400/day. He
lives with his family in a 1-storey house made of wood with a water-sealed toilet. Drinking water is from
LMWD. He usually wakes up at 5am eats breakfast usually composed and fish and rice then goes to
work. He is a smoker for 10 pack year and occasional alcoholic beverage drinker. He negates exposure to
flood but with rodents at home and there are stagnant waters at their neighborhood.
Review of systems

Review of systems:

Negates weight loss,, (+) body malaise since onset of illness

Skin: no itchiness, no recurrent skin lesions, no rashes

Eyes: no blurring of vision, does not wear eyeglasses, (-) discharges

Ears: (-) hearing loss, (-) pain, (-) discharges

Nose: (-) colds, (-) anosmia, (-) pain, (-) epistaxis

Mouth and throat: (-) pain, (-) dysphagia, (-) hoarseness

Neck: (-) mass, no stiffness

Respiratory: (-) cough, (-) dyspnea, (-) pleuritic chest pain

Heart: (-) palpitations, (-) easy fatigability, (-) paroxysmal nocturnal dyspnea

Abdomen: (+) anorexia since onset of illness, (-) abdominal pain, (-) BM changes, Defecates 1x per day
with formed stools

GUT: (-) dysuria, (-) hematuria, (-) urinary frequency, (-) flank pains, urinates 3-4x a day

Extremities: (-) joint pains, (-) swelling or edema, (+) myalgia

Endocrine: (-) polyuria, (-) polydipsia, (-) heat and cold intolerance

Hematologic: no easy bruising, (-) gum bleeding

Peripheral vascular: (-) intermittent claudication, (-) recurrent pain on extremities, (-) numbness, (-)
cramps

Musculosketal: (-) muscle cramps, (-) bone pains

Neurologic: (-) seizures, (-) recurrent headache, (-) dizziness, (-) loss of consciousness, (-) head trauma

Physical examination:

Examine awake, conscious, coherent, mesomorph, well-developed, in respi ratory distress with
following VS:

BP- 80/60 mmHg HR-118 bpm RR-19 cpm Temp-38.9 oC O2 sat-98% (room air)

Skin: no active skin lesions, (-) rashes, (-) peripheral cyanosis, moist, good skin turgor, capillary refill <2
sec

HEENT: (+) slightly icteric sclerae, (+) conjunctival suffusion, pinkish conjunctiva, (-) eye discharges,
turbinates not inflamed, (-) nasal discharge, dry lips and tongue, tonsils not enlarged, thyroid gland not
palpable, (-) NVE
Chest and Lungs: Symmetrical lung expansion, unimpaired tactile fremitus, resonant on all lung fields
with bronchovesicular breath sounds

Heart: Adynamic precordium, (-) visible pulsations, PMI at 5 th ICS LMCL, (-) heave, (-) thrill, (-) murmur,
tachycardic with regular cardiac rhythm

Abdomen: full, symmetric, (-) scar, no localized bulging, no palpable mass, Liver edge palapable 3cm
below subcostal margin with a span of 14cm, spleen not palpable, (-) tenderness, tympanitic in all
quadrants, NABS, (-) KPS

Extremities: (+) calf muscle tenderness bilateral, pulses 1+