IM WARD SECTION 3C - DR.

SAM UY

General Data:
Date of Interview: October 4, 2018 Informant: Patient
History taken by: MA. DANICA LOUISE M. LUNA Patient reliability: 80%

Identifying data:
Jason Solangon Doloso, 20 years old, male, single, Filipino, Roman Catholic, born on September 15, 1998
in Quezon City, currently residing at 15 Holy Spirit, Payatas A, Quezon City, admitted for the first time at FEU-NRMF
Medical Center on October 3, 2018.

Chief Complaint: HIGH GRADE FEVER FOR 3 DAYS

History of Present Illness:

Three days prior to consult patient went to Quezon City Circle in the morning to do their project, while
doing their project he started feeling dizzy, after that he went home, on the same day afternoon the patient had
fever with a temperature of 39C, self medicated with Bioflu 500 mg at 7pm and Biogesic 500 mg 12 midnight but
fever still persisted with nausea and abdominal pain.
Two days prior to consult the patient still with fever with temp of 39C and nausea with headache of 6/10,
abdominal pain of 9/10. He self medicated again with Paracetamol (Biogesic) 500 mg at 7am and Medicol 250mg
but still symptoms persist. Around 4pm still with fever of 38C, takes Paracetamol (biogesic) 500 mg, at around 7pm
still with fever which is 40C, takes Paracetamol (biogesic) 500 mg.
One day prior to consult, at 7am still with fever of 39C, with the same associated symptoms takes
Paracetamol (biogesic) 500 mg again. At 3pm, due to unrelieved symptoms despite taking medication, he went to
the nearby lying-in center at Payatas, the in-charge personnel requested for CBC and urinalysis, which later
interpreted as low platelet and noted with UTI. He was prescribed with several medication: Isoprinosine 500 mg, 1
tab 4x/day, Sodium ascorbate 1 cup 2x/day and ORS 1 liter per day. Symptoms and fever of 40 C still persisted
despite of taking medications with with headache of 7/10, abdominal pain of 7/10, difficulty of sleeping and loss of
appetite.
On the day of consult, the patient can no longer sleep, nauseous, loss of appetite with body malaise.
Hence, this prompted consult at 2am in FEU-NRMF Medical Center. The physician ordered laboratory tests and
gave Pantoprazole 40 mg IV and Paracetamol 60 mg IV. At around 10:38am, patient was admitted to the institution
after laboratory results came out.

Past Health Illness:

No known childhood diseases

Immunization is claimed to be complete
Has asthma, non hypertensive, non diabetic
No known allergies in food and drugs, heart diseases, cerebrovascular accident, and cancer

Family History:

Mother: Leonesa Doloso, 43, apparently well

Father: Andrew Doloso, 44, apparently well
Siblings: John Paul, 17, and Andrew Doloso Jr 12, both had history of Dengue last July 2017

Paternal side: no known history of heredo-familial diseases

Maternal side: Grandmother had kidney surgery and Grandfather had Splenic cancer

No family history of Hypertension, Diabetes Mellitus, Heart diseases, Arthritis; No history of stroke, Blood
disorders, Obesity, Psychiatric Illness, Seizure Disorders, Tuberculosis, Sexually Transmitted Infections.

Personal and Social History:

The patient is a 5th year computer engineering student. Lives in a in a two-storey concrete house, well-lit, well-
ventilated. The source of water is fromNawasa, and garbage is collected 3x/wk. He sleeps 6 hours a day, drinks 1
cup of coffee/day. Not smoker nor an alcoholic beverage drinker . Fond of eating fatty foods and salty foods. No
regular physical exercise . No history of illicit drug use.

Review of Systems:

Constitutional Symptoms
(-) weight loss (-) fatigue (-) chills (-) inc appetite (+) generalized body weakness
Skin
(-) itchiness; (-) excessive sweating; (-) change in color (cyanosis, pallor, jaundice, erythema)
Eyes
(-) pain; (-) blurring of vision; (-) double vision; (-) lacrimation; (-) photophobia
Ears
(-) earache; (-) deafness; (-) tinnitus; (-) ear discharge
Nose and Sinuses
(-) changes in smell; (-) nose bleeding; (-) nasal obstruction; (-) nasal discharge; (-) pain around paranasal sinus
Mouth and Throat
(-) toothache; (-) gum bleeding; (-) disturbance in taste; (-) sore throat; (-) hoarseness
Neck
(-) pain; (-) limitations of movement; (-) presence of mass
Respiratory System
(-) chest pain; (-) cough; (-) sputum production; (-) hemoptysis;
Cardiovascular System
(-) substernal pain; (-) palpitations; (-) orthopnea; (-) paroxysmal nocturnal dyspnea; (-) easy fatigability
Gastrointestinal
(-)- dysphagia; (-) constipation; (-) hematemesis, (+) diarrhea
Genitourinary Tract
(-) dysuria; (-) polyuria; (-) hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge
Extremities
(-) edema (-)swelling of joints; (-) stiffness; (-)numbness; (-)intermittent claudication;(-) limitation of movement
Nervous System
(-) vertigo; (-) syncope; (-) loss of consciousness; (-) paralysis; (-) numbness; (-) paresthesia; (-) speech disorder; (-)
loss of memory; (-) confusion
Hematologic
(-) bleeding tendencies; (-) pallor; (-) easy bruising
Endocrine System
(-) heat/cold intolerance; (-) excessive weight gain/loss; (-) polyuria; (-) polydipsia

Physical Examination

General Survey
The patient is conscious, alert and responds to verbal tactile and painful stimuli. He is oriented to time, place, and
person. Looks his stated age and appears to be well kempt. Cooperative and responsive to all questions that were
asked. He did not have any difficulty of speaking and was able to talk spontaneously and comprehend,
communicate and express his ideas. His memory was intact, with a euthymic mood, and had an appropriate affect.
Has normal weight and well nourished. Hypersthenic. There were no signs of distress

Vital Signs
Patient is normotensive (110/80). The pulse rate (74 bpm), cardiac rate (93 bpm) , respiratory rate (23 cpm) and
temperature (38.3 C) are normal. Patient is 65 kg and 5’7” and has a BMI of 22.4 which is normal.

Skin
Skin is brown, normal degree of moisture, elasticity, mobility and thickness with good skin turgor. Nails are
smooth and pink, with normal nail folds.

Head
Hair is thick, black with grayish area, evenly distributed,coarse and dry. Head is normocephalic symmetrical,
without swelling, no tenderness and masses. Temporal arteries are not visible but palpable with strong equal
pulsations. Walls not thickened.

Face
Face is oval, symmetrical, brown. Normal facie and no involuntary facial movements, no visible mass.

Eyes
Evenly distributed eyebrows and eyelashes, curled outward without matting. Eyelids have intact skin, no discharge
or discolorations, no ptosis. They close symmetrically with bilateral blinking. Negative lid lag. Palpebral
conjunctivae are pinkish. Normal set of eyeballs, no exophthalmos nor enophthalmos, no nystagmus. Non Icteric
sclera. Corneas are transparent, no lesions. Patient’s pupils are equal in size, round and has smooth border. Iris is
flat and round. Patient’s direct and consensual light reaction is normal. Lenses are transparent. Fundoscopic exam
revealed (+) ROR 2:3 AV ratio.

Ears
The patient has symmetrical auricles, auditory canal is patent, with minimal brownish discharge on both ears, walls
are pink without lesions, tympanic membrane is pearly white and intact, normal contour with visible cone of light
and has no perforation.

Nose and Paranasal sinuses

Symmetrical without lesions, deformities and tenderness, ala nasi not flared. Nasal septum is in the midline,
without perforations, mucosa is pinkish and turbinates are flat and dry. Nasal cavity is patent without discharges.
Frontal and maxillary sinuses exhibit no tenderness and positive transillumination.
Mouth and Pharynx
Lips are pink, dry, symmetrical, without lesions. Buccal mucosa is pink and smooth. Tongue is at the midline, no
fasciculation nor lesion. Hard and soft palate is pinkish, no lesions, uvula is at the midline.

Neck
Neck is normal in size, symmetrical without visible mass,swelling or deformation with full of range of motion. No
neck vein distention. Trachea is in the midline, no palpable lymph nodes. Thyroid gland is neither visible nor
palpable.

Thorax and Lungs

The skin is brown with a brown papule on the left parasternal line, thorax is elliptical and symmetric in shape with
good expansion; no kyphosis. No deformity and chest muscles are well developed and chest wall movements are
symmetrical, with no use of accessory muscles. No retractions. Chest has no scars. No dilated blood vessels. No
chest wall tenderness. No costo-vertebral angle tenderness. Normal tactile fremitus, equal over all lung fields.
Lung sounds resonant over all fields. Vesicular breath sounds are heard in all lung fields, no rales and rhonchi
present. No bronchophony, egophany, or whispered pectoriloquy noted.

Cardiovascular
No visible neck vein. Flat precordium. Carotid arteries pulsation is strong, regular rhythm, equal pulsations and soft
consistency of the wall. Apex beat is adynamic, located at 5th ICS, 1 cm from LMCL, approximately 1x2 cm in
diameter, normal amplitude. No abnormal precordial pulsations, thursts, lifts, heaves, thrills and palpable heart
sounds. Normal intensity of heart sounds appreciated, no abnormal heart sounds.
Symmetrical arms and legs, warm to touch. No edema, pallor, pigmentation, hair loss, dilated varicosities and
lesions. Brachial and radial artery palpable at 3+. Popliteal and dorsalis pedis with full pulsations at 3+. Regular
rhythm, equal pulsations and soft consistency.

Abdomen (lacson okay na)

Abdomen is symmetrical, light brown, flat, inverted umbilicus. No visible pulsations, peristalsis and dilated vessels.
No lesions, scars, and bulging flanks. Normoactive bowel sounds. No bruit heard over the epigastrium, right and
left paraumbilical area. All abdominal quadrants are tympanitic on percussion. No abdominal mass upon palpation.
Liver is non palpable. Spleen is not palpable. Right and Left Kidneys are not palpable. No pain was elicited when
performing Kidney Punch. Negative Rebound tenderness, Psoas sign, Obturator sign and Murphy’s sign.

Neurologic Evaluation

Cerebrum:
The patient has GCS: E:4 V:5 M:6, conscious, cooperative, appropriately groomed, oriented to time, place, and
person. Is able to recall memory, appropriate mood and affect and no emotional lability. Can understand and
communicate in spoken and written language, able to recognize an object by the use of primary senses, and has
the ability to conceive, formulate and execute complex, purposive, skilled, volitional acts on command.

Cranial nerves:
CN I: nose is patent, can identify the smell of tobacco
CN II: can read the smallest letters of the Jaeger chart at a distance of 14 inches, (+)ROR, clear media, and distinct
disc margin. Normal AV ratio, no hemorrhages, no visual field defect
CN III, IV, VI: both pupils constrict briskly reactive to light both direct and indirect. Adduction of both eyes and
constriction of both pupils on accommodation. Equal and complete opening of both eyes, can move eyes in 6
cardinal directions of gaze
CN V: can feel pain and light touch equally on both sides. Prompt and equal blinking of both eyes in corneal reflex.
Can clench teeth equally on both sides
CN VII: can frown, raise the eyebrows, and close eyes equally on both sides. Nasolabial folds are equal
CN VIII: intact gross hearing, responsive to verbal sounds
CN IX & X: no dysphonia, uvula at midline, equal elevation of palate on phonation, (+) gag reflex
CN XI: can turn head from side to side against resistance, can elevate shoulders equally
CN XII: no atrophy nor fasciculation, tongue midline on protrusion, can move tongue from side to side

Cerebral Function:
Normal finger-nose-finger test, is able to perform rapid alternating movement by patting her knees with the palm
and the back of her hands by pronation and supination, smooth movement and the heel remain on the shin (-)
dysmetria, romberg’s test and tandem walking was not performed.

Motor Function:
Size and consistency of the the muscle are normal. No atrophy or fasciculation. Normal symmetry of postures,
muscles contours and outlines. Normal muscle tone. There are no resistance to passive movements, no latent
paralysis, no pronation drift, and no involuntary movements. Flexion, extension and other movements through the
major joints without resistance and with resistance are graded with grade 5/5 on all extremities.