PATIENT’S HISTORY

SURNAME: Jacolbe AGE: 11 year old HOSPITAL NO: 536694

GIVEN NAME: Mark Ian SEX: Male WARD: Pedia Ward
MIDDLE NAME: Blaya CS: Child BED NO:

General Data This is the case of M.I.J., 11-year old, male, Filipino, Roman Catholic, born on May 14, 2007. She is presently residing at Basud, Brgy. 4 (Pob.,
Malilipot, Albay. This is patient’s 1st admission in this institution.

INFORMANT: Mother and patient herself

RELIABILITY: 95%

CHIEF COMPLAINT: Fever

HISTORY OF PRESENT ILLNESS:

5 days prior to admission, patient had a high fever, documented (38.7 C) associated with headache (frontal area), nausea and vomiting (4x, non projectile, non-bilious,
non-bloody). Patient was given Paracetamol tablet 2x which afforded slight relief. No consult done.

4 days prior to admission, still with the same signs and symptoms, patient had abdominal pain in the periumbilical area. No medications given. No consult done.

Few hours prior to admission, persistence of symptoms accompanied with body weakness and circumoral cyanosis prompted consult at Ziga Hospital which referred
patient to BRTTH for further evaluation and management. Hence, admission.

REVIEW OF SYSTEMS:

General (-) weight loss (-) loss of appetite (-) fatigue (-) weakness
Integumentary (-) discoloration (-) changes in nails and hair (-) pallor (-)cyanosis
Head (-) dizziness
Eyes (-) redness (-) discharge
Ears (-) discharge (-) pain
Nose (-) nosebleed (-) colds
Throat (-) gum bleeding (-) lumps (-) dysphagia
Neck (-) lumps (-) swollen glands
Respiratory (-) hemoptysis (-) DOB
Cardiovascular (-) chest pain (-) palpitations (-) orthopnea
Gastrointestinal (-) constipation, (-) melena (-)abd pain
Genitourinary (-) flank pain (-) dysuria (-) discharge
(-) hematuria
Musculoskeletal (-) myalgia (-) arthralgia
Neurologic (-) irritability (-) changes in behavior
Hematology (-) easy bruising

PAST PERSONAL HISTORY:

A. GESTATIONAL HISTORY
The patient was born to a 37 year old G4P3 (3003) mother who had regular prenatal check-ups at Barangay Health Center. Mother did not took Ferrous
Sulfate, Folic acid, and multivitamins during pregnancy. Mother had no complications during pregnancy. No known exposure to teratogenic radiation and
drugs. The mother claims that she is not a smoker and a non-alcoholic beverage drinker.

B. BIRTH HISTORY
After hours of labor, patient was born term, cephalic in presentation delivered via NSD at home by a ‘kumadrona’. No cord coiling and meconium staining
noted. The patient had a good cry and motor activity upon birth.

C. NEONATAL HISTORY
No jaundice was noted. Passage of flatus and bowl movement was observed in the first 24 hours of life. New Born Screening was done which revealed normal
results. Patient had good suck and activity..

D. IMMUNIZATION HISTORY
Mother claims that the patient has a complete immunizations, no Rotavirus and PCV under the DOH EPI Program in the local health center.

PAST ILLNESSES

(-) Allergy
(-) PTB
(-) Chicken pox
(-) Measles
(-) Bronchial Asthma:
(+) Past Hospitalization: Intestinal Parasitism (2008)
 (-) Previous surgeries:

FAMILY HISTORY
(+) Asthma, maternal (-) DM
(-) Allergy (-) BFC
(-) Hypertension (-)Heart disease
(-) Hereditary spherocytosis (-)PTB

H.E.A.D.S
The patient lives with 7 household members in a bungalo house built with light and heavy materials. Patients house is near the sea. Patient lives with his parents.
Mother is a housewife and father is a carpenter. They have shared comfort room with septic tank, use firewood for cooking, and drinking water is from a Nawasa.
Garbage disposal is through compost pit. He is in Grade 5 with average marks. He claims that he doesn’t smoke nor drinks alcohol. He claims that he doesn’t have a
boyfriend and he is not sexually active.

PHYSICAL EXAMINATION

General Survey:
The patient is awake, afebrile, ambulatory and not in cardio respiratory distress.

Vital Signs
BP 90/60 mmHg Temp: 38.6 C CR:94bpm RR: 20cpm 02 sat: 97%

Anthropometric measurements:
Weight 26.8 kg

Height 136 cm

BMI 14.49 kg/m2

Skin: brown complexion, no rash, warm and dry, with good skin turgor and mobility (-)pallor (-) jaundice
Head and Neck: normocephalic and atraumatic, no lumps and tenderness, neck is supple, no cervical lymphadenopathies, trachea is in midline,
Eyes: nonicteric sclerae, (-) conjunctival injection, pink palpebral conjunctiva (-)sunken eyeballs
Ears: no discharge, non tender
Nose: patent, no masses or lesions, (-) discharge, no septal deviation (-)alar flaring
Throat and Oral: pink and moist oral mucosa, non enlarged, non hyperemic tonsils
Chest & Lungs: symmetrical chest expansion, (-) intercostal retractions, (-) crackles (-) wheezes
Cardiovascular: adynamic precordium, (-) adventitious sounds (-) murmur
Abdomen: flat, normoactive bowel sounds, tympanitic upon percussion, without hepatomegaly and splenomegaly, soft, periumbilical area tenderness upon
light or deep touch
Extremities: full, strong pulses, CRT<2 sec, (-) bipedal edema, no gross deformities, with good muscle bulk and tone, no clubbing of fingers, no axillary
lymphadenopathies, (-) joint pains

Neurological Examination

Mental Status The patient is alert

Cranial Nerves Cranial Nerves
I patent

II Pupils equally reactive to light and

accommodation

III, IV, VI Patient can follow object in all

directions

V (+) corneal reflex

VII No facial asymmetry

VIII Able to follow direction of sound

IX, X Able to swallow

XI Positive for shoulder shrug

XII Tongue in midline

Motor Muscles are of good bulk and tone, strength in all extremities are 5/5
Sensory patient reacts upon stimulation with light touch in face and all extremities
Cerebellar Not done

ADMITTING DIAGNOSIS:
Dengue Fever with Warning signs
Prepared by:

Chanelle N. Filio
BUCM Junior Intern