DAVAO MEDICAL SCHOOL

FOUNDATION, INC.
PEDIATRIC DEPARTMENT

Franco, Krista Kamille

Frasco, Jan Mikhail
Galigao, Kenneth Anthony
Gabriel, Norlie

August 26, 2016

GENERAL DATA
Patient Name: T.P.
Age: 17
Birthday: November 11, 1998
Sex: Female
Civil Status: Single
Address: Bankerohan, Davao City
Date/Time Admitted: August 23, 2016 4:00pm
Date/Time Interviewed: August 24, 2016 3:30pm
Informant: Mother Reliability: 75 %
CHIEF COMPLAINT
Fever, Vomiting
HISTORY OF PRESENT ILLNESS
2 days prior to admission, patient experienced sudden
onset of headache with undocumented fever, took
Paracetamol (Saridon) 500 mg, afforded no relief.
HISTORY OF PRESENT ILLNESS
1 day prior to admission, still with fever and headache,
now accompanied by abdominal pain, with nausea and
non-bilious, non-projectile vomiting amounting to
approximately 2 cups. Took Paracetamol 500mg po for the
fever. No other associated findings noted, no consult done.
HISTORY OF PRESENT ILLNESS
16 hours prior to admission, worsening of symptoms noted, now
with accompanying body malaise and retro-orbital pain. Sought
consult at a local hospital. Noted to have moderate grade fever
(38.8C); Laboratory tests were done, Urinalysis and CBC Normal,
with platelet count of 162. She was given Paracetamol +
Orphenadrine (Norgesic forte) 1 tablet TID, and Domperidone
(Motilium) 1 tablet TID for vomiting.
HISTORY OF PRESENT ILLNESS
10 hours prior to admission, fever not relieved now with associated
joint pains and body malaise.

Persistence of findings prompted admission.

PAST MEDICAL HISTORY
Previous Hospitalization

Date/Duration/Age Chief Complaint/ Hospital/Clinic

Diagnosis/ Treatment
February 2012: Abdominal Pain and Fever Private Hospital
Admitted for 3 days Diagnosis: Hypercidity Cotabato City
12 years old Omeprazole 20 mg
capsule x 3 days
PAST MEDICAL HISTORY
SURGICAL HISTORY:
She did not undergo any surgical procedures

ALLERGIES:
Penicillin
No food allergies
FAMILY HISTORY
Father hypertensive since the age of 40
No other history of hereditary diseases in the family
BIRTH/PREGNANCY HISTORY
Mother was 29 years old when she got pregnant with the
patient (third among 3 siblings)
No use of any family planning method
First prenatal visit: 6 weeks AOG Private OB Gyne
Given:
Multivitamins 1 capsule OD
No Hepatitis B Vaccine
PERINATAL HISTORY
G3P3 (3003)
Born via NSVD in a Local Hospital (Cotabato City)
Labor lasted from 3am 10:40 am
Good cry as claimed by the mother
no complications of delivery were noted
POSTNATAL
Immunization schedule at the Barangay Health Center was
followed and completed.
Breastfed for 3 month
Formula feeding
S26 at 3 months
Solid foods: 6months (Cerelac)
Vitamins: unrecalled
DEVELOPMENTAL MILESTONES
First tooth: 6.5 mos
Sit without support: 8 months
Able to walk at 10 mos
Unable to recall other developmental milestones
DIET/NUTRITIONAL HISTORY
Not a picky eater
Diet: Rice and 1 viand
Skips Breakfast, drinks coffee instead
Frequently cooks own dinner at home.
Loves to drink cola (1-1.5 Liters /day)
No intake of any vitamins
SOCIAL HISTORY
Living with Brothers
Parents live in Cotabato City
Sophomore in BS Pharmacy
Volleyball varsity
SOCIAL HISTORY
Hangs out with her friends and goes home around 8pm
Social drinker (2-3 bottles of beer) and smokes 2 sticks of cigarette at the
same time
No use of any illicit drugs
Spends leisure time strolling around malls or sleeping
ENVIRONMENTAL HISTORY
Lives with her 2 brother in a boarding house in Bangkerohan.
Building:
Made of wood
Window screens not installed
Own comfort room
Shared kitchen and dining area
Open canals and manholes outside
Tap water serves as their water source.
REVIEW OF SYSTEMS
Constitutional symptoms: (-) Weight loss, (+) fever, (+) loss of appetite, (+)
weakness
Skin: (-) itchiness, (-) excessive drying and sweating, (-) cyanosis, (-)
jaundice, (-) Pallor
Head: (-) dizziness, (-) numbness, (-) vertigo
Eyes: (-) photophobia, (-) blurring of vision, (-) double vision, (+) retro-orbital
pain
Ears: (-) earpain, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and sinuses: (-) change in smell, (-) nose bleeding
REVIEW OF SYSTEMS
Neck: (-) pain, (-) limitation of movement
Respiratory: (-) hemoptysis, (-) chest pain, (-) difficulty in breathing
Cardiovascular: (-) syncope, (-) easy fatigability, (-) palpitation, (-) orthopnea
Gastrointestinal: (-) dysphagia, (-) diarrhea, (-) constipation, (+) nausea, (+)
vomiting, (+) abdominal pain
Genitourinary: (-) urinary frequency, (-) dysuria, (-) incontinence , (-)
hematuria
Nervous system: (-) numbness, (-) loss of memory, (-) confusion (-) loss of
consciousness
REVIEW OF SYSTEMS

Extremities: (+) joints paints, (-) stiffness, (-) numbness, (-) limitation of
movement
Hematopoietic: (-) bleeding tendency, (-) pallor, (-) easy bruising, (-) history of
transfusion reaction
Endocrine System: (-) intolerance to heat and cold, (-) excessive weight gain
or weight loss
PHYSICAL EXAMINATION
General
Patient lies comfortably, Awake, conscious, coherent, oriented to
time and person, Not in respiratory distress
Stands 5 feet and 2 inches and weighs 63 kilos
BMI 25.2kg/m2
Vital Signs
BP- 110/70 mmHg (Supine)
CR- 85 bpm
RR- 19 cpm
Temp- 38.9 degrees Celsius
Physical Examination

Skin
Fair skin color
No echymosis and lesions
Warm and dry to touch
Good skin turgor
Head
Hair is black, equally distributed and well groomed
Physical Examination
Eyes
pink palpebral conjunctiva
Pupils equally round, 3mm in size, isocoric and reactive to light
and accommodation
No lesions, dryness or inflammation were noted
EOMs intact
Physical Examination
Ears
Auricles symmetric in position
No discharge, foreign bodies, redness or swelling of ear canal
No signs of irritation or lesions
Non tender
Nose and Sinuses
Pink mucosa
Midline septum
No lesions or discharges
No nasal flaring
No tenderness of frontal or maxillary sinuses
Physical Examination
Mouth
Pink and moist lips
Pink oral mucosa and gums, without any lesions
Tongue is pink and at midline
Uvula midline
Tonsils not inflamed
Teeth slightly yellow with good dentition

Neck
Midline trachea, no anterior neck mass
Jugular veins are not distended
Carotid pulsations noted in both sides
No lymphadenopathies
Normal neck range of motion
Physical Examination
Thorax and Lungs
Symmetrical chest expansion
No observable deformities, masses or lesions noted
No tenderness
Equal tactile fremitus
Resonance, with no dullness
Clear breath sounds

Cardiovascular
Precordium is symmetrical
No thrills and heaves
Point of maximum impulse at 5th intercostal space midclavicular
HR is 85 bpm with normal rhythm
No abnormal heart sounds or murmurs
Physical Examination
Breast
Not assessed

Abdomen
No lesions or post operative scars noted.
Normoactive bowel sounds with 15 clicks per minute.
Pain upon palpation at epigastic region with a painscale of 4/10.
Liver edge palpable 2-3 fingerbreadths below the right subcostal
margin.
Physical Examination
Extremities
Fair skin complexion, both upper and lower extremities symmetrical in shape
No joint deformities, lesions, or ulcerations
Warm and without edema
Capillary refill of 2 sec, without clubbing and cyanosis
Axillary, brachial, posterior tibial, and dorsalis pedis pulses are 2+ and
symmetrical
Full range of motion
Physical Examination
Mental Status
Awake and conscious, GCS of 15
Relaxed, pace, capable of voluntary full range of motion with firm movement
With appropriate facial expressions
Able to communicate with appropriate affect
Talks with intermediate rate of speech and minimal loudness
Oriented to person, date, time, and past
Able to remember past events
Cranial Nerves
I- Smell accordingly
II- Equal visual fields
III, IV, VI- Pupils are equally reactive, isocoric, 3mm diameter, intact EOM
V- Clench teeth, feel soft touches on face, intact corneal reflex, symmetrical
facial grimace
VII- Project facial expression without difficulty
VIII- Hear whispered voice, AC>BC, lateralization on both ears
IX,X- Swallow and speak without difficulty
XI- Shrug shoulder against resistance with equal strength
XII- Move tongue freely
Impression
Dengue fever with warning signs
Salient features:
Fever- 38.9 degrees Celsius
Abdominal pain
Headache
Nausea
Vomiting
Fatigue
Myalgia
Arthralgia
Retro-orbital pain
Menstruation (3rd day)
Hepatomegaly
Thrombocytopenia
Rainy season
DIFFERENTIAL DIAGNOSIS
CHIKUNGUNYA
RULE IN RULE OUT

Fever (-) severe joint pain, prolonged.

Arthralgia (-) conjunctival infection

Myalgia (-)maculopapular rash

Thrombocytopenia
Abdominal pain
Headache
Nausea
ENTERIC FEVER
RULE IN RULE OUT
Fever (-) gastroenteritis
Abdominal pain (-) constipation
Hepatomegaly (-) rose spots
Headache (-) coated tongue
Nausea (-) relative bradycardia
Vomiting
Thrombocytopenia
Arthralgia
Malaise
MALARIA
RULE IN RULE OUT
Headache (-) Paroxysm
Fatigue (-) exposure to malaria endemic areas
Abdominal discomfort (-) orthostatic hypotension
Myalgia (-) temp of above 40 degrees Celsius
Fever (-) tachycardia
Nausea (-) mild jaundice
Vomiting (-)chest pain
LEPTOSPIROSIS
RULE IN RULE OUT
Fever Not exposed to contaminated
Headache waters like flood and no contact
Myalgia with animal urine or blood.
(-) jaundice
Abdominal pain
Hepatomegaly (-)rashes
(-)conjunctival suffusion
Final Diagnosis
DENGUE FEVER WITH
WARNING SIGNS
Ethiopathogenesis

Acute febrile illness of 2-7 days duration

Four distinct viruses (Flaviviridae)
Vector: Aedes aegypti (Stegomyia family)
Incubation period: 2-7 days
Clinical Manifestations
Classic symptoms:
Sudden onset of fever (+)
Headache (+)
Retro-orbital pain (+)
Back pain (-)
Severe myalgia (+, but only mild to moderate)
Maculopapular rash (-)
Clinical Manifestations
Other signs and symptoms:
Anorexia (+)
Nausea and Vomiting (+)
Cutaneous hypersensitivity (-)
Common Diagnostic Tests
CBC (+)
Dengue IgM and IgG (ELISA)
NS1 Antigen (Rapid) test
Tourniquet Test (+)
WHO Classification of Dengue
DENGUE FEVER
DENGUE FEVER WITH WARNING SIGNS
SEVERE DENGUE
DENGUE FEVER WITHOUT WARNING SIGNS
Lives in/travels to dengue endemic area
Fever (+) and any 2 of the following:
Nausea and vomiting (+)
Rash
Aches and pains (+)
+ tourniquet test
Leukopenia
Any warning signs
DENGUE FEVER WITH WARNING SIGNS
Abdominal pain or tenderness (+)
Persistent vomiting (+)
Mucosal bleed
Lethargy or restlessness
Liver enlargement >2cm (+)
Hct concurrent with rapid in paltelet count
SEVERE DENGUE
Severe plasma leakage
Severe bleeding
Severe organ involvement
PHASES
FEBRILE
CRITICAL
RECOVERY
Management
Dengue Fever without Warning Signs
Adequate bed rest
Adequate fluid intake
Paracetamol PRN
Management
Dengue Fever with Warning Signs
Hydration
Encourage OFI if tolerated
IVF
Monitoring
VS q1-4 hrs
Hct at baseline and q6-12 hrs
Management
Severe Dengue
Initial resuscitation: isotonic crystalloid solutions
Treatment of hypotensive shock: crytalloid or colloid
solution
Treatment of hemorrhagic complications:
5-10 ml/kg of pRBC or 10-20 ml/kg fresh whole blood
PREVENTION
4S STRATEGY AGAINST DENGUE
Search and Destroy
Self-protection measures
Seek early consultation
Say no to indiscriminate fogging