Clinical History

A. General Data
a. Name:
b. Age:
c. Birth Date:
d. Sex:
e. Birthplace:
f. Religion:
g. Present Address:
h. Number and Date of Hospital Admissions
i. Name of Informant and Relation to Patient:
j. Reliability
B. Chief Complaint
C. History of Present Illness
a. 6 days PTA
i. Patient complained of frontal headache and
retrorbital pain with a pain rate of 5/10. No
accompanying rash, fever, cough, colds, chills,
coryza, and joint pains. Headache was relieved by
Biogesic 500 mg taken once a day. No consult was
done.
b. 5 days PTA
i. Headache persisted but with accompanying fever
with unrecorded temperature and body malaise. The
patient continued taking Biogesic but still no consult
was done.
c.
d. 3 days PTA
i. The above symptoms of the patient persisted
accompanied by anorexia. Biogesic
e. 1 day PTA
i. The patient
Additional Questions
- chills,
- bed rest
- hydrate
abdominal pain
diarrhea
D. Review of Symptoms

E. Personal History
a. Development and Behavioral History
b. HEADS/S/FIRST
Home
Education
Abuse
Drugs
Safety
Safety
Sexuality/Se
xual Identity
Family and
Friends
Image
Recreation
Spirituality &
Connectedn
ess
Threats &
Violence
c. Menstrual History
Menarche
Duration
Frequency
Problems in Menstruation
d. Self Breast Examination
F. Past Illnesses
Contagious Diseases:
Past admissions
Surgeries
Allergy
Asthma
Injuries
G. Immunization History
H. Family History
a. Parents
Age
Occupation
State of health
If not living, age and cause of death
b. Siblings
Number

Ages
State of health
c. Familial Illness or Anomalies
TB
DM
Cancer
Epilepsy
Rheumatic fever
Allergy
I. Socioeconomic History
Place and nature circumstances of dwelling
Number of persons living in the house
Sources of funds
J. Environmental History
Exposure to cigarette smoke
Garbage disposal
Sewage disposal
Water source
Flooding
Physical Examination
a. General Survey
Mental state, sensorium, level of activity
Ambulatory bed ridden
State of hydration
b. Vital Signs
Temp
BP
PR
RR
c. Anthropometric Data
Height
Weight
d. Skin
Color
Turgor
Rash
Hemorrages
Scar
Edema
jaundice
e. Head
Hair quantity
Color
Texture
Lice and nits

f.

g.

h.

i.

Strength
Face
Asymmetry
Expressions
Deformities
lumps
Eyes
Lids
Conjunctiva
Sclera size, rxn to light
Pupils
Eom - H
Vision snellen
ROR dx set
Corneal light reflex penlight
Ears
Size
Shape
Location
Position
Discharge
TM dx set
Continuity
Intact or perforated
Color
Cone of light
Bulging/concave
Nose and Paranasal Sinuses
Patency of nares
Discharge
Position of septum
Sinus tenderness

j. Mouth and Throat

Lips color,moisture, dryness
Throat tongue dep penlight
Gums color, lesions, bleeding
Tongue midline, color, moisture, abnormal movements
Oropharyngeal mucosa thrush, vesicles, ulcers, Koplik spots
k. Neck
Flexibility
Masses
Lymph nodes
Swelling
Thyroid

Trachea
l. Chest and Lungs
m. Heart
n. Abdomen
o. Inguinal Region
p. Genitalia
q. Extremities
Neurological Examination
Salient Features
HPI
Physical
Exam
Approach to Diagnosis
Differential Diagnoses
Working Diagnosis
Diagnostic Laboratory Exams
Virus isolation Virus can be recovered from acute phase serum
after inoculating tissue culture or living mosquitoes.
NS1 Antigen a reliable point of care diagnosis of acute dengue
infection where a viral nonstructural protein, NS1, is released by
infected cells into the circulation and can be detected using
monoclonal or polyclonal antibodies.
PCR Detects viral RNA in blood or tissues by specific
complementary RNA probes
Serologic Tests Following primary and secondary dengue
infections, there is relatively transient appearance of anti-dengue
immunoglobulin (IgM) antibodies. These disappear after 6-12
weeks, a feature that can be used to time a dengue infection. In
second primary infections, most antibody is of the IgG class.
Torniquet Test
Complete Blood Count pancytopenia may occur after 3-4 fays
of illness. Neutropenia may persist or reappear during the latter
stage of the disease and may continue with convalescence.
Monitor hematocrit and platelet count for possible hematologic
abnormalities and progression to dengue hemorrhagic fever or
dengue shock syndrome.

Treatment
Uncomplicated dengue fever is supportive. Bed rest is advised
during the febrile period. Antipyretics should be used to keep body
temperature <40 C. Analgesics or mild sedation may be required to
control for pain. Aspirin is contraindicated and should not be used
because of its effects on hemostasis. Fluid and electrolyte replacement
is required for deficits.
Vital signs, degrees of hemoconcentration, dehydration, and
electrolyte imbalance must be monitored. Transfusions of fresh blood
or platelets should not be given during hemoconcentration, but only
after evaluation of hemoglobin and hematocrit values