SAINT LOUIS UNIVERSITY

HOSPITAL OF THE SACRED HEART

DEPARTMENT OF PEDIATRICS

GANIBAN, Hestia Kate O. Preceptor: Dr. Tolentino

3A, Group 10 March 13, 2019

I. GENERAL DATA
This is the case of V.B., 3 year old female child, Filipino, Roman Catholic, born on May 28, 2015 in Benguet and
currently residing at Ambuklao, admitted last March 12, 2019 at SLU-HSH. The informant was the patient’s mother with
a reliability of 85%.

II. CHIEF COMPLAINT

Fever and Rashes

III. HPI
The condition started 5 days PTA when the patient felt easily tired after playing and complained of headache.
The patient then had a fever with 39.6oC as the highest recorded temperature. She was treated with Paracetamol
(Myremol) 5 mL every 4 hours which gave temporary relief. She was also advised to have a bed rest and to increase
water intake. No other associated signs and symptoms such as cough and colds, and the patient still had good appetite.
4 days PTA, the fever persisted ranging from 38-40oC. No associated signs and symptoms, and still with good
appetite.
3 days PTC, the patient complained of generalized abdominal pain and headache. She also had 1 episode of
vomiting after food intake, approximately ½ cup, white, liquid with food particles, no blood, and no mucus. They sought
consult at a private pediatrician where she was also noted to have tonsillitis and was prescribed with Clarithromycin 4 mL
to be taken in the morning and in the evening and Paracetamol (Tempra) 5 mL every 4 hours. They were also asked to
return after 2 days if there are other signs and symptoms that will manifest. Fever started to gradually lyse after intake of
the prescribed drugs.
2 days PTA, the patient had low grade fever. No other associated signs and symptoms noted.
1 day PTA, the mother noted rashes on the patients back, upper and lower extremities. The patient also
complained that the rashes were itchy and was constantly scratching. A midwife was called and they were advised to go
to the hospital.

IV. PERSONAL HISTORY

A. FEEDING HISTORY
The patient eats 3 main meals a day and has snacks in between. She is a picky eater and is spoon-fed. She has no
food intolerance or allergies. A sample diet of the patient is as follows:

Components Estimated Caloric Total (Kcal)

Value (Kcal)
Breakfast Rice (1/2 cup) 102 202
Vegetables (1/4 cup) 16
Milk (Friso – ½ cup) 84
Lunch Rice (1/2 cup) 102 118
Vegetables (1/4 cup) 16
Dinner Rice (1/2 cup) 102 202
Vegetables (1/4 cup) 16
Milk (Friso – ½ cup) 84
Snacks Banana 40 160
Cookies (1 pack) 120
TOTAL 682
RECOMMENDED NUTRITIONAL INTAKE FOR AGE (FEMALE) 1260
REMARKS Inadequate intake
 B. DEVELOPMENTAL HISTORY
i. Physical growth:
Height 98cm/ 0.98 m
Weight 14.5 kg
BMI 15.1 kg/m2
Tanner Scale 1
AC 46 cm

ii. Developmental milestones

Gross motor Fine motor Communication and Cognitive
Language
Alternate feet in Copies a circle Uses plural and obeys Counts 1-10
climbing stairs propositional
commands
Puts on shoes Plays simple games

C. PAST ILLNESS
The patient was diagnosed with Acute Gastroenteritis at age 10 months old, was admitted at
SLU-HSH for 4 days, and treated with Co-trimoxazole for 7 days. The condition recurred at age 1 and was again
hospitalized on the said institution for 4 days, and treated with Co-trimoxazole and Metronidazole. At age 2, she
had high fever with convulsion, was admitted at Baguio General Hospital for 3 days.
No common childhood illnesses such as measles, mumps, and chickenpox. No known allergies to food
and medications. No history of trauma, fall or accidents, and previous surgeries. No congenital anomalies noted.

D. IMMUNIZATION HISTORY
The patient’s childhood immunizations were received at a local health center with the following details

Vaccine 1st dose 2nd dose 3rd dose Reactions

BCG 03/28/15 Scar on the right
deltoid
Hep B 03/28/15 No adverse reactions
DTwP/DTaP Unrecalled Unrecalled Unrecalled noted
OPV Unrecalled Unrecalled Unrecalled
IPV Unrecalled
Hib Unrecalled Unrecalled Unrecalled
Rotavirus Unrecalled
PCV Unrecalled Unrecalled
Flu vaccine Unrecalled Unrecalled

V. FAMILY HISTORY
Both parents are apparently in good health and have no known diseases. The patient is the third child. Older
siblings are also alive in good health. There is a family history of hypertension in both the paternal and maternal side.
Positive allergy to chicken in the paternal side. No history of other heredofamilial diseases such as diabetes mellitus,
arthritis, pulmonary tuberculosis, cardiovascular diseases, asthma, cancer, psychiatric problems, hematologic problems,
seizures and congenital problems noted.

VI. SOCIAL-ENVIRONMENTAL HISTORY

The patient’s father is 37 years old, a construction worker, and is the provider of the family’s financial resources;
mother is 33 years old, a housewife and the primary caregiver of the patient. The first sibling is 15 years old, a grade 9
student while the second sibling is 13 years old, a grade 7 student. They live in a concrete, well-ventilated 1-storey house
with 2 rooms and 1 flushed-type toilet. Their home has 5 occupants, to include the patient, her 2 older siblings and
parents. Water source for drinking purposes comes from boiled tap water. Garbage is segregated and collected weekly.
They have 6 dogs (outdoor) and 8 cats (indoor). No history of recent travel. The patient’s neighborhood playmate and
mother also have the same condition as the patient and are admitted in a different hospital.

VII. REVIEW OF SYSTEM

General: (+) fever, (+) chills, (+) fatigue, (-) weight change
Skin: (+) rash, (+) itching
Head and neck: (+) headache, (-) pain, (-) trauma
Eyes: (+) pain, (-) tearing
Ears: (-) pain, (-) discharge
Nose: (-) pain, (+) discharge
Mouth: (+) pain, (+) soreness, (-) hoarseness
Respiratory: (-) cough, (-) dyspnea, (-) wheezing
Cardiovascular: (-) chest pain/discomfort
Gastrointestinal: (+) anorexia, (+) nausea/retching (+) vomiting, (+) abdominal pain, (-) hematochezia
Genitourinary: (-) dysuria, (-) hematuria
Musculoskeletal: (-) muscle pain, (-) joint pain, (-) cramps, (-) weakness
Neurological: (+) headache

VIII. PHYSICAL EXAMINATION

General survey: Awake, conscious, neatly and appropriately dressed, no signs of cardiopulmonary distress

Vital signs
Cardiac rate 99 bpm
Respiratory rate 31cpm
Temperature 36oC
SpO2 98%

Anthropometric Measurements
Height 98 cm/ 0. m
Weight 14.5 kg
BMI 15.1 kg/m2 (underweight)
Length for age Z score: ()
Weight for age Z score: ()
BMI for age Z score: ()
AC 46 cm

Skin: Skin is fair, warm, moist, and smooth to touch, no cyanosis, no jaundice, diffuse, coalescent maculopapular
rashes

HEENT:

Head: normocephalic, even hair distribution, black in color, smooth, no masses, no deformities,
Eyes: eyes are symmetrical, eyeballs not sunken, no periorbital edema, anicteric sclera, no discharges,
pupils briskly reactive to light and accomodation
Ears: symmetrical and normally set, no lesions, on otoscopy the cone of light is noted on the right ear
with minimal non-impacted cerumen, view of tympanic membrane on the left ear is obstructed by thick
non-impacted cerumen
Nose: patent nose, no alar flaring, no nasal discharge
Mouth: lips are moist and pinkish in color, no circumoral cyanosis, no cleft lip or palate, buccal mucosa
is moist and pinkish, no ulcers, no bleeding, uvula at the midline, no tonsillopharyngeal wall congestion,
22 teeth in total (upper left central incisor, lateral incisor, canine teeth having dental caries) and (left
lower first molar and canine tooth having dental carie)
Neck: no rigidity, no masses, no venous engorgement, no lymphadenopathy
Chest and Lungs: Chest is rectangular, no intercostal retractions, symmetric lung expansion, resonant upon
percussion, no wheezing, crackles or grunting

Heart: PMI located on the 4th ICS left ICS, S1 more audible at the apex and S2 more audible at the right and left
parasternal borders, regular rate and rhythm, no murmurs, heaves or thrills,

Abdomen: Globular, umbilicus located midline and not protruded, no visible peristalsis or organomegaly, no
paradoxical breathing, no lessions/masses, no tenderness upon light and deep palpation, liver span is 4cm
midclavicular line, tympanitic upon percussion, normoactive bowel sounds, and no aortic bruits,

Genitalia: Grossly female, no masses, no discharges, Tanner scale grade 1

Extremities: No gross deformities, no cyanosis, pinkish nail beds with capillary refill of less than 2 seconds, non-
pitting edema on both upper extremities, more prominent on the left arm, non-pitting edema on the lower
extremities extending up to the distal2/3 of the legs, peripheral pulses are grade 2+, symmetric and regular on
both upper and lower extremities

Neurologic:
Cerebrum: awake, conscious, able to identify mother
Cerebellar: no tremors or nystagmus
Cranial Nerves:
CN I Not assessed
CN II Pupils are equally round and reactive to light with direct
and consensual reflex.
CN III, IV, Intact extraocular movements
VI
CN V Clenches jaw
CN VII With facial symmetry
CN VIII Responds to auditory stimuli
CN IX, X Uvula at the midline
CN XI Moves head side to side, shrugs shoulders
CN XII Protrudes tongue

Motor: good muscle tone, no flaccidity or muscle atrophy

Sensory: Responds to tactile stimuli
Problem List:
1. Headache, fever, nausea, vomiting, abdominal pain, rashes, edema

Problem #1: Headache, fever, nausea, vomiting, abdominal pain, rashes, edema

Subjective Data:
 3 year old, female
 5 days PTA: easily got tired after playing, had headache then fever (39.6o - highest recorded
temperature), treated with paracetamol, bed rest, and increase water intake
 4 days PTA: persistence of fever (38-40oC)
 3 days PTA: generalized abdominal pain and headache, 1 episode of vomiting after food intake, sought
consult – diagnosed to have tonsillitis, prescribed with antibiotic and paracetamol, fever started to lyse
 1 day PTA: rashes on the back, upper and lower extremities
 No history of recent travel.
 Neighborhood playmate and mother have the same condition as the patient

Objective Data:
 General survey: Awake, conscious, neatly and appropriately dressed, no signs of cardiopulmonary
distress
 Vital signs: CR: 99 bpm; RR: 31 cpm; T: 36°C, SPO2: 98%
 Skin: diffuse, coalescent maculopapular rashes
 Eyes: symmetrical, eyeballs not sunken, no periorbital edema, anicteric sclera, no discharges
 Nose: patent nose, no alar flaring, no nasal discharge
 Mouth: buccal mucosa is moist and pinkish, no tonsillopharyngeal wall congestion,
 Chest and Lungs: no wheezing, crackles or grunting
 Abdomen: no visible organomegaly, no paradoxical breathing, no lessions/masses, no tenderness,
tympanitic upon percussion, normoactive bowel sounds, and no aortic bruits,
 Extremities: non-pitting edema on both upper extremities, more prominent on the left arm, non-pitting
edema on the lower extremities extending up to the distal2/3 of the legs
 Cranial nerves: intact
 Motor strength: good muscle tone, no flaccidity or muscle atrophy
 Sensory function: responds to tactile stimuli

A. Assessment:
 Dengue Fever with warning signs

 Basis:
The signs and symptoms of Dengue Fever are consistent with the patient’s clinical presentation as can be
seen in the table below.
Classic features of Dengue Fever Patient’s signs and symptoms
Sudden onset of fever, with temperature rapidly +
increasing to 39.4-41.1°C
Headache +
Frontal or retro-orbital pain +
Myalgia and arthralgia -
Nausea and vomiting +
Anorexia +
Sore throat +
Weakness +
Maculopapular rash appears that spares the +
palms and soles
Edema of sparing palms and soles +
Pathogenesis: Dengue presents in a nonspecific manner similarly to that of many other viral and bacterial illnesses.
Fever typically begins on the third day of illness and persists 5-7 days, abating with the cessation of viremia. Fever may
reach 41C°.
Leukopenia, lymphopenia near the end of the febrile phase, and thrombocytopenia are common findings in dengue fever
and are believed to be caused by direct destructive actions of the virus on bone marrow precursor cells. The resulting
active viral replication and cellular destruction in the bone marrow are believed to cause the bone pain. Approximately
one third of patients with dengue fever may have mild hemorrhagic symptoms, including petechiae, gingival bleeding, and
a positive tourniquet test. Dengue fever is rarely fatal.

 Differential Diagnoses:

Differential diagnoses Rule in Rule out

Measles High fever Cough, coryza, conjunctivitis
Maculopapular rash Koplik spots
Serology
Influenza Fever
Headache
Sore throat

B. Plan:

Diagnostic  Isolation of the virus, virus antigen, or genome by polymerase chain reaction
(PCR) analysis and determination of fourfold or greater increase in antibody
titers: during the febrile or early stages of illness
 NS1 antigen test: 24 hours after the onset of illness
 Complete blood count: To determine presence of an infection. The total white
blood cell (WBC) count and differential may aid in determining if an infection is
bacterial or viral in etiology.
Therapeutic Specific:
 Paracetamol: for relief of fever; act primarily in the CNS, increasing the pain
threshold by inhibiting both isoforms of cyclooxygenase, COX-1, COX-2, COX-
3 enzymes involved in prostaglandin synthesis.
 ORS: to prevent electrolyte imbalance
Supportive:
 Bed rest
 Adequate fluid intake (2-3L per day)
Educative  Eliminated breeding places
 Use of mosquito nets
 Use of insect repellant lotions