St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
SCHOOL OF MEDICINE

Pediatric Case Write-up

Aguinaldo, Krista
Aquino, Gerald Dr. Grandelee Taquiqui
Castillo, Rianne

Informant: Patient and his father

Information reliability: 95%
Date and time of history: January 15, 2019 (1:30PM)

I. GENERAL DATA
This is the case of patient J.D., a 10-year old male, a Filipino, Roman Catholic,
born on August 26,2008, and presently residing at Baggao, Cagayan. He was admitted
for the second time in Cagayan Valley Medical Center (CVMC) last January 14, 2019.

II. CHIEF COMPLAINT

Fever

III. HISTORY OF PRESENT ILLNESS

The patient is apparently well until 4 days prior to admission when patient had
fever which is documented at 39 degrees celcius. Patient also had headache characterized
as pulsating, continuous, non-radiating, rated as 7/10 (interferes with concentration),
relieved by rest and sleep accompanied by brown watery stool. He also experienced
episodes of non-projectile vomiting of about 3 times a day, each vomitus amounting to
half a glass, whitish in appearance and mostly of undigested food, occurring every after
meal. Paracetamol and ORS were initially given by his mother prior to consult at the
District Hospital.
3 days prior to admission, with persistence of the above condition, now the patient
presented with loss of appetite and weakness. Medications were continuously given
2 days prior to admission, still with the above condition, patient was again
brought to the District hospital. CBC was done and medications were continuously given.
Few hours prior to admission, With the persistence of the said condition and
recurrence of fever, patient was then referred to CVMC; hence, the subsequent
admission.
IV. PAST MEDICAL HISTORY

Childhood Illnesses None

Previous hospitalization CVMC (2012)
Burn Injury
Surgical History None
Psychiatric None
Allergies None
Medications/ Supplements Multivitamins

The patient did not have previous illnesses. There were no surgical and psychiatric history
however, patient was admitted last 2012 at CVMC due to burn injury. He has no known allergies
to food and drugs. He is given multivitamins as supplement.

V. GESTATIONAL, BIRTH AND NEONATAL HISTORY

PRENATAL HISTORY: The mother was recalled to have regular prenatal check ups at
RHU. She was recalled to have taken necessary vitamins/ medicines such as Folic acid,
Ferrous sulfate and Vitamin C, to have given Tetanus Toxoid shots and to have been in
good medical condition within the duration of her pregnancy.

NEONATAL HISTORY: Patient was born to a 1-year old mother, G2P2 (2-0-0-2), full
term with cephalic presentation, delivered via NSVD at Callang, Hospital. Mother was
reported to have no feto-maternal complications after delivery. Thus, no noted jaundice,
cyanosis, convulsion or respiratory distress. Birth weight was 5kg and Newborn
Screening was done.

V. NUTRITIONAL HISTORY

Patient was breastfed for about 2 years with a combination of formula milk at 8months.
There were no noticeable reaction with breast milk observed. Introduction of food other
than milk started at 7 months. Patient is given multivitamins as supplement.

VI. GROWTH AND DEVELOPMENT

Parents did not notice any delay in growth and development particularly with
developmental milestones.
VII. IMMUNIZATION HISTORY

Vaccine Dose/s
BCG 1
Hepa B 3
Pentavalent 3
(DPT,OPV,Hib)
MMR 2
PCV none
Patient has completed EPI duly given by the Health Center except for PCV shots.

VIII. FAMILY HISTORY

Both his father and mother’s side were reported to have no known medical
conditions such as Hypertension, DM, heart diseases, asthma. There were no other
heredo-familial diseases noted. The patient’s sibling is reported to be of good
medical condition.
.
IX. PERSONAL AND SOCIAL HISTORY

Patient is the youngest child. His father, 38, works as a farmer while his mother,
28, is an OFW. His father and grandmother are the primary caregivers.

Patient, together with his father, grandmother and sibling, lives in a simple
bungalow concrete house with a comfort room located inside the house. They
raise agricultural animals (hens, pigs) at the backyard. Their primary source of
water is deepwell which also serves as their source of drinking water which
usually is not boiled.
X. REVIEW OF SYSTEMS
 GENERAL
 There was no delay in growth observed.
INTEGUMENTARY HEAD CARDIAC RESPIRATORY GASTROINTESTINAL
Gastrointestinal
(-) Abdominal pain
(+) Rashes (+) headache (-) Palpitations (+) Cough,colds (+) Abdominal pain (+) Loss of appetite
(-) Pigmentation (-) dizziness (-) Chest pain (-) Dyspnea (+) Loss of appetite
(-) Loose bowel movement
(-) Bloody stool
(-) Hair loss (-) visual difficulty (-) Tightness (-) Hemoptysis (-) Loose bowel (-) Hematemesis
(-) Constipation
(-) Cyanosis (-) lacrimation (-) orthopnea (-) chest pain movement (-) Vomiting
(-) Pallor (-) hearing (-) cyanosis (-) Bloody stool (-) encopresis
(-) Passage of worms
(-) Pruritus (-) aural discharge (-) easy fatigability (-) Hematemesis(-) Food intolerance
(-) Jaundice (-) nasal discharge (-) fainting spells (-) Constipation
(-) Pica

(+) epistaxis (-) Vomiting

(-) toothache (-) encopresis
(-) salivation (-) Passage of worms
GENITOURINARY CNS
(-) ENDOCRINE
sore throat (-)MUSCULOSKELETAL
Food intolerance
(-) Dysuria (-) Change in behavior
(-) Excessive sweating (-)(-)Pica
pain in bone
(-) change in color of urine (-) Seizures
(-) palpitations (-) myalgia
(-) burning sensation (-) tremors
(-) cold/ heat intolerance (+)weakness
(-) discharge (-) sleep problems
(-) polyuria (-) swelling in bone
(-) frequency (-) convulsions
(-) polydipsia (-) limitation of motion
(-) enuresis (-) weakness or paralysis
(-) polyphagia (-) stiffness
(-) Oliguria (-) mental deterioration (-) limping
(-) Flank pain (-) mood changes
(-) Hematuria (-) Temper outbursts
(-) hallucinations

XI. PHYSICAL EXAMINATION

General survey
The patient is seen lying on the hospital bed, awake, conscious, and not in
cardiorespiratory distress.

Vital Signs

TEMPERATURE 36.4 °C (axillary)

HEART RATE 72 bpm

RESPIRATORY RATE 25 cpm

BLOOD PRESSURE 90/60 mmHg

WEIGHT 22 kg

HEIGHT 132cm
 BMI 12.62 kg/m2

ARM CIRCUMFERENCE 19 cm

I: (-) Bruises, petechiae

(-) Jaundice, pallor, cyanosis
SKIN
P: Warm to touch
Good skin turgor

I: Normocephalic
HEAD
P: (-) Palpable Masses, Lesions

I: (-) Redness
(-) Icteric
EYES Equally Round, both reactive to light
and accommodation
Pink palpebral conjunctiva

I: Normal-shaped pinna
TM: pearly gray color on otoscope
EARS
(-) discharge
P: (-) lesions, mass or tenderness

I: Midline septum
NOSE (-) Lesions
(-) nasal discharge, flaring
 I: (-) inflammation of tonsils, bleeding and
swelling gums
(-) oral thrush
THROAT & MOUTH
Pink and moist oral mucosa
Uvula and Tongue midline
Good Dentition

I: Midline septum
NECK
P: (-) Palpable lymph nodes, masses

I: Symmetrical
(-) Retractions
CHEST and LUNGS
P: Symmetrical Chest Expansion
A: (-) Rales, Crackles, Wheezes

P: (-) Thrill
A: Point of Maximal Impulse (PMI) on 5th
CARDIO-VASCULAR
ICS-LMCL
Normal Rate, Regular Rhythm

I: Flat
(-) Scars, lesions or rashes
A: Hypoactive Bowel Sounds
ABDOMEN
P: Tympanitic
P: Soft, non-tender
(-) mass, distention, organomegaly

I: Symmetrical Extremities

MUSCULOSKELETAL Good ROM

SYSTEM Normal Gait
P: (-) Tenderness

PERIPHERAL I: Pink nail beds

VASCULAR SYSTEM
(-) edema, clubbing of nails
 P: Full and equal pulses (CRT <2s)

Mental Status: Patient is awake and alert

Oriented to person, place and
time
Cranial Nerves: Intact
Motor: Good motor strength (5/5)
NEUROLOGIC
DTR: Biceps: 2+
Triceps: 2+ (Average, expected
Brachioradialis: 2+ response, normal)
Patellar : 2+
Achilles Tendon: 2+

XII. SALIENT FEATURES

 Age (10y/o)
 Prevalence of same cases in the community
 High Grade Fever
 Vomiting
 Diarrhea
 Loss of appetite
 Weakness
 Rashes
 Headache
 Epistaxis
 Abdominal pain

XIII. DIAGNOSIS

Dengue with warning signs

XIV. DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT 1.

 High grade fever  Fever pattern - relapsing MALARIA
 Vomiting  No chills
 Abdominal pain  No profuse sweating
 Diarrhea  Chills/convulsions
 Weakness  No rashes
 Headache
2. TYPHOID FEVER

RULE IN RULE OUT

 High grade fever  Fever pattern - reemittent
 Vomiting  No cough
 Abdominal pain  Onset of rashes (within days)
 Diarrhea  Location and characteristics of
rashes
 Weakness
 Headache

3. INFLUENZA

RULE IN RULE OUT

 Headache  Low-grade fever
 Vomiting  No nasal congestion
 Abdominal pain  No rashes
 Diarrhea  No sore throat or cough
 Weakness