Patient’s Name: Mark Intia Hospital: DLS-UMC

Informant: Lilibeth Intia (Mother), Irene Ramos (Aunt) Department:Pediatrics

Reliability: Good Preceptor: Dr. Simbul
Historian: Salvatore Juliano M. Elardo Date of Admission: 07/12/2018
Group No.: Date of Wardwork: 07/12/2018

GENERAL DATA

Mark Intia, male, 6 year-old, Filipino, Roman Catholic, was born on February 11, 2002 in
Camarines Sur, Bicol and is currently residing in General Trias, Cavite, was admitted for the first
time last July 11, 2018 in DLSUMC.

CHIEF COMPLAINT: “Nangitim ang labi at nag karoon ng chills”

HISTORY OF PRESENT ILLNESS

The patient was apparently well until 4 days prior to admission when, according to the
informants, the patient experienced fever (no recorded temperature), he was then given
paracetamol every four hours until the next day. In the morning of the next day, the patient’s fever
had disappeared and the patient was able to attend school. However, during the evening the fever
returned and persisted until the night before admission where the patient experienced chills, cold
extremities, and darkening of lips which prompted the patient’s caregivers to seek medical
attention. According to the informant, Mark was the only person in his class who had become ill.
And that he liked to play in the rain before he started having fevers.

REVIEW OF SYSTEMS

General: (+) weight loss, (+) loss of appetite, (+) poor activity, (-) dehydration, (-
) growth delay, (-) weight gain, (-) pigmentation

Integument: (-) wound, (-) rashes, (-) erythema, (-) pallor, (-) clubbing of nails, (-)
hyper/hypopigmentation

Head & Neck: (+) headache, (+) cyanosis, (-) palpable lymph node, (-) stiffness, (-)
edema, (-) neck vein distention, (-) mass, (-) dizziness

Eyes: (-) periorbital edema, (-) pain, (-) redness, (-) corrective lens, (-) discharge

Ears: (-) otalgia, (-) vertigo, (-) tinnitus, (-) difficulty of hearing

Nose & Sinuses: (-) discharge, (-) colds, (-) epistaxis, (-) obstruction

Mouth & Sinuses: (-) inflamed tonsils, (-) toothache, (-) hoarseness, (-) dysphagia, (-) ulcers,
(-) tongue fasciculation

Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) tachypnea, (-) pleuritic chest pain
Cardiovascular: (-) angina, (-) palpitations, (-) orthopnea, (-) tachycardia

GIT: (+) abdominal pain, (-) vomiting, (-) anorexia, (-) nausea, (-) diarrhea, (-)
abdominal distention, (-) ascites, (-) constipation

GUT: (-) scrotal edema, (-) penile edema, (-) polyuria, (-) nocturia, (-) dysuria,
(-) flank pains

Hematologic: (-) easy bruising, (-) easy bleeding, (+) pallor

Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia

MSS/ Extremities: (-) edema of the extremities, (-) fracture, (+) joint pains

CNS: (-) seizures, (-) syncope, (-) tremors, (-) slurring of speech

PAST MEDICAL HISTORY

The patient has a history of UTI and no other past illnesses (Mumps, Measles), and was
hospitalized once for a shoulder dislocation. He was given Ibuprofen in the duration of his injury.
He has no history of TB, pneumonia, allergies, asthma, ear anomalies, and eye problems. The
patient also has no history of any operation or surgeries.

FAMILY HISTORY

The patient’s maternal aunt has history of hypertension. No other heredofamily disease
were noted such as DM, cardiac disease, renal disease, seizure disorder, congenital defects,
intellectual disorder, and behavioral problems. There is also no history of communicable disease
in the family such as TB and HIV.

BIRTH AND MATERNAL HISTORY

Prenatal: The patient was born to a G6P6 (6006) mother who was 29 years old. The pregnancy
was planned. The mother of the patient stated that she had complete prenatal consults every
month before the delivery. The mother has no experience of Gestational Diabetes or
Hypertension, spotting, and PROM. During pregnancy, work-ups like ultrasound, CBC, urinalysis,
and OGCT/OGTT were done. The mother has no history of hospitalizations and exposure to any
toxic substances and took Klobicol Obe during prenancy.

Perinatal: The duration of labor was unrecalled by the mother. She was not given anesthetics
and has no known complications during birth.

Postnatal: The patient was born term, vaginal deliverym at her home attended by a midwife. The
birth weight of the patient was 1.8kg while the birth length was unrecalled by the mother. The
patient was not admitted to the NICU. The mother states that the patient had newborn screening
exams, including hearing screening and eye examination.

DEVELOPMENTAL HISTORY

The development of the patient is at par with age and no red flags were noted.
Developmental Milestones (6-12 Normal (in years) Actual (in years)
years)
Gross Motor
Climb and Run 7 years 7 years
Fine Motor
Copy letters 6 years 6 years
Reverse some letters 6 years 6 years
Know right and left sides 7 years 7 years
Language
Verbalize emotions 6 years 6 years
Follow 3 serial commands 6 years 6 years
Personal-social
Dress up completely 6 years 6 years

NUTRITIONAL HISTORY

The patient was breastfed until 12 months old. The patient was introduced to
complementary feeding at 12 months and table food at 4-years-old. The mother said the patient
is given 2 meals/day and 1 snack/day and has a poor appetite, his food preference includes
chicken joy and fast foods and less likely to eat vegetables. He is difficult to feed and does not
like vitamins.

IMMUNIZATION HISTORY

 Informant claims that complete

vaccines were given to the patient

PERSONAL AND SOCIAL HISTORY

The father of the patient is a 35 year old finance trafficker and the mother of the patient is
a 34-years-old housewife. He lives with his parents, who are only living together and not married,
and with his caretaker, in laws, and 5 other siblings. The primary caretaker of the patient is his
aunt. The patient is the 5th child of his mother out of 6. The patient is exposed to the different
kinds of gadgets such as the television, video games, and smart phones. The usual duration of
screen time is 4 hours a day. Patient mostly has videogames as his hobby.
ENVIRONMENTAL HISTORY

The patient has no exposure to cigarette smoke and other pollutants. Garbage from their
house is segregated properly but collected once a month. Water source is from Water District and
Purified for drinking.

PHYSICAL EXAMINATION
GENERAL SURVEY
The patient is alert, awake, and uncooperative towards the examiner. He is well
developed, fairly nourished, and conscious. He exhibits no signs of cardio-respiratory distress but
is irritable. He appears her chronological age of 6.

VITAL SIGNS

HR: 96 bpm
RR: 21 bpm
Temperature: 38.4 C, axillary
O2 stat: 98%
IV line: right hand

ANTHROPOMETRIC MEASUREMENTS

Weight: 19.6 kg
Height: 130 cm
BMI: 11.6

SKIN
Upon inspection of the patient there is no pallor, no jaundice, no erythema, no lesions, no
hair loss/excess, no nail clubbing, no cyanosis, and no edema.

Upon palpitation, extremities are cold to touch, good skin turgor, prompt capillary refill, no
dryness of the skin or hyperhidrosis.

HEAD AND NECK

Upon inspection of the patient he has symmetrical features. Hair is black in color, normal
density, soft and smooth in texture, no pattern of hair loss. No prominent facial edema.

Upon palpitation, no presence of mass, palpable lymph nodes, enlarged glands and
tenderness were noted.
EYES
Eyelids of the patient were symmetrical, with pink conjunctiva and no masses or
ulceration, and has no ptosis but the presence of severe periorbital edema was noted.

ENT
Ear
Patent external auditory canal with no mass nor lesions. No ear discharge was noted.

Otoscopy not done.

Nose
The external nose is symmetrical, aligned vertically with the midline and free of
any masses, deformities or tenderness. The external nares are equal in size and shape.
The nasal septum is in midline. Both nostrils are patent. No lesions and discharge.

Mouth and Throat

The lips are symmetrical, pinkish, and devoid of masses or ulcerations. The oral
mucosa and gums are smooth, pinkish, and free of masses and ulcerations. Tongue is in
the midline and is mobile and no noted lesions.

CHEST AND LUNGS

Upon inspection, chest and chest expansion is symmetrical, with no use of accessory
muscles, no retractions, nor lesions or deformities. On palpation, there are no tenderness.
Upon auscultation, the patient has clear breath sounds and no adventitious sounds noted.

CARDIOVASCULAR
Upon inspection and palpation, no visible pulsation over various parts of the chest and the
epigastrium, no precordial bulge noted. Patient’s apex beat was not assessed. There are no
heaves and thrills. On auscultation no extra murmur was heard and the bronchovesicular breath
sounds can be heard on all lung fields. The patient’s heart rate was 96 bpm.

ABDOMEN
Upon inspection, he has a flat abdomen with no abdominal scars, discoloration, visible
mass, nor visible peristalsis/pulsations, and has an inverted umbilicus. On auscultation, the
patient was tympanitic. Upon palpation and percussion, the patient has a soft, non-tender, flat
abdomen.

EXTREMITIES
The hands and feet of the patient are cold to touch but there was no presence of lesions,
masses, deformities and tenderness in the upper and lower extremities. No clubbing or cyanosis
in the nail beds.

NEUROLOGIC EXAM
 The patient is awake and alert, and irritable on PE, noted to have a bad mood and he is
dressed appropriate according to age. Irritability of the patient was due to pain from the IV line on
his hand.

CASE DISCUSSION
SALIENT FEATURES
 6-years-old boy
 Recurrent fever
 Cold extremities
 Darkening of periorbital region
 Poor feeding habits and diet
 Plays in the rain

PRIMARY IMPRESSION: C
.
This is a case of 6-years-old boy who went to our institution due to chills and discoloration
of the perioral region as well as low temperature of the extremities. Viral infections are common
among children and most are not serious. There infections include a variety of diseases such as
loss of appetite, fever and body aches or discomfort. Viruses cannot be cured using antibiotics
rather, the alleviation of the symptoms is the main focus of treatment. These symptoms are easily
treated with safe drugs such as acetaminophen and ibuprofen and proper nutrition and rest. As
such, the long term prognosis of the patient is good.

Differential Diagnosis

Diseases Rule in Rule out

Dengue (+) recurring fever, (+) loss of (-) rashes, (-) joint pain
appetite

Plan of Management

Diagnostics:
 Complete blood count: to check for neutropenia to support the primary impression
 Torniquet test – to rule out dengue

Therapeutics:
Non-pharmacologic:
 Proper nutrition, continue IV dextrose if patient still refuses to eat
 Bed rest and sufficient sleep
 Monitoring of body temperature
 Continued follow up for monitoring of the disease
 Pharmacologic:
 Paracetamol for the discomfort and fever.

References:
 R. Kliegman, B. Stanton, J. St. Geme, N. Schor. Nelson’s textbook of Pediatrics
(20th ed.). New York City, NY: McGraw-Hill Education