CASE

PRESENTATION

 This is a case of M.A., 3y.o, female, was admitted for the

second time at Makati Medical Center

IDENTIFYING DATA:

 CHIEF COMPLAINT: Fever

 One week prior to admission productive cough, given

Salbutamol 2.5mg/2.5ml, 5 ml every 12 hours, with no relief.
No fever, no fast breathing noted.
One day prior to admission onset of fever (Tmax: 38),
vomiting of previously ingested food approximately 100ml. No
abdominal pain, no rashes, no hematuria, no gum bleeding.

HISTORY OF PRESENT ILLNESS

 Night prior to admission persistence of cough, fever

and vomiting. Patient given Paracetamol 120mg/5ml, 5
ml every 4 hours and provided temporary relief. No gum
bleeding, no abdominal pain, no rashes, no hematuria.
Morning prior to admission, persistence of symptoms and
now with headache hence brought to Makati Medical
Center Emergency Room and was subsequently admitted.

HISTORY OF PRESENT ILLNESS

 33 y.o G1P1 (1001)

Prenatal check up: 1 month AOG to 9th month AOG with
frequency of 11 times, conducted by OBGYNE.
No maternal illnesses noted & no medications taken
during pregnancy. No history of exposure to radiation,
abortion, premature uterine contraction, bleeding or
vaginal discharges.

PRENATAL HISTORY

 Patient was delivered full term via NSVD assisted by an

Obstetrician at a Hospital in Cavite, cephalic
presentation, with 6 hours of active labor.
Umbilical cord was cut using sterilized scissors &
sloughed off for 6 days.
No complications observed at the umbilical area..

BIRTH HISTORY:

 Patient was pinkish upon birth with good cry and

vigorous movements.
No dyspnea, fever, convulsions or bleeding noted.
Meconium and urine was passed few hours after
breastfeeding.
There were no complications noted.

NEONATAL HISTORY:

 Patient was breastfed until 6 months.

Supplemental feeding of solid food was introduced at 6
months with mushed fruits and vegetables, frequency of
1-2 times a day.

FEEDING PATTERN:

AGE GROSS MOTOR

4mos. Head control in prone
7mos. Sits with support
12 mos.
Walks w/o support
16 mos.
Runs
ADAPTIVE FINE MOTOR
4 mos reaches for objects
5.5 mos
transfers object hand to hand
10 mosholds bottle
15 mosdrinks from cup
24 mosfeeds well with spoon
3 yr runs well

GROWTH AND DEVELOPMENT:

LANGUAGE
NB Crying
9mos Speaks mama
15 mos. Says both mama and papa
3 yr Knows full name
Cognitive
8 mos. Uncovers toys
17 months pretend play

 BEHAVIOR:
Patient usually wakes up at 7am & sleeps at 8pm. No
mannerism noted.
IMMUNIZATION:
complete
At birth: BCG ID @ deltoid: Hepa1 IM after birth
6 weeks: Hepa2: DPT1 IM; OPV1 oral
10 weeks: DPT2, OPV2
14 weeks: Hepa3; DPT3; OPV3
9 mos: Measles
MMR 2 doses

 PAST MEDICAL HISTORY:

(+) 2015- UTI at Makati Medical
FAMILY HISTORY:
Heredofamilial disease: (-) asthma, (-) hypertension, (-)
DM(-), Cancer, (-) Thyroid Disease, (-) Heart Disease

 Sources of support: family

Coping style: play
Activities at Home and School: performs well in class
and usually plays with her toys at home

PSYCHOSOCIAL HISTORY:

 GENERAL SURVEY: Patient was examined conscious,

awake, ectomorph, febrile, with ff. vital signs and
anthropometric measurements:
HR
159
90-110
RR
20
24-40
Temp
39.3
36-37.5
O2 sat
98% (room air)
98-100%

PHYSICAL EXAMINATION

ACTUAL IDEAL
SCORE
HC
48cm
49
-1
CC
54cm
AC
53cm
Height 94cm
97cm
-1
Weight 14kg
14kg
0
BMI 15.8
15
0

 INTEGUMENT: warm to touch, no rashes, no active lesions, no

hypo/hyperpigmentation, no central or peripheral cyanosis, no
edema, with good capillary refill.
HEAD:
Hair: short, straight, black, fine
Scalp: no lumps, no tenderness, no scars, no engorged veins
Skull: normocephalic, temples not depressed
EYES:
Eyelids: no lidlag, no sty
Conjuctiva: pinkish palpebral conjunctiva
Sclera: anicteric, no hemorrhages
Cornea: no ulcerations, no opacities
Pupils: equally reactive to direct & consensual light, constrict
2mm in diameter

 EARS: symmetric, no discharges, no active lesions, no

impacted cerumen
NOSE: No nasal discharges, no deformities, no septal
deviations
MOUTH & THROAT:
Lips: Pinkish, no angular drooping, no sores
Mucous membrane: dry, no bleeding, no sores
Gums: pinkish, no bleeding
Tongue: uvula @ midline, tonsils not enlarged
NECK: trachea @ midline, no engorged veins, no visible
pulsation, no palpable lymph nodes
BREAST: symmetric, no discharges

 CHEST & LUNGS:

I: symmetric, no lagging, no retractions
P: resonant all lung fields
A: clear breath sounds
AXILLA: no palpable lymph nodes
HEART:
I: adynamic precordium, apical impulse not visible
P: regular rhythm synchronous with
pulses, no murmurs

 ABDOMEN:
I: full, no visible peristalsis, no
hypo/hyperpigmentation, no visible bulging,
umbilicus not inverted
A: soft, spleen, kidneys, liver not palpable, no
costovertebral tenderness
EXTREMITIES:
I: symmetrical, no deformities, no lesions, no
edema, no cyanosis
P: full, equal pulses

 MENTAL STATUS EXAM: Patient is conscious,

coherent, irritable, uncooperative.
CRANIAL NERVES:
I. Not tested
II. Pupils constrict to 2mm in diameter, symmetric,
briskly reactive to direct & consensual light

NEUROLOGIC EXAMINATION:

III,IV,VI full & intact EOM

V. motor: temporal & masseter muscle strength intact
Sensory: intact facial sensation
VI. no facial asymmetry upon crying
VIII. Not tested
IX,X Intact gag reflex
XI. Not tested
XII. No tongue deviations, no atrophy

 MOTOR: good muscle bulk and tone, no flaccidity and

spasticity
CEREBELLAR: intact
SENSORY: pinprick, light touch, position sense intact
REFLEXES: DTR: 2+; Pathologic reflexes: negative
AUTONOMICS: no excessive hunger or thirst, no cold
or heat intolerance, no urinary and bowel incontinence.

 Dengue Fever with no warning signs

ADMITTING IMPRESSION

 Salient Features:
fever
vomiting
headache

 PLAN:
Admit
Diet for Age, except dark colored food
Diagnostics: CBC, Platelet
Urinalysis
Blood culture and sensitivity
PT, PTT, SGPT
Procalcitonin

Medications:
Paracetamol 250mg/5ml 3.5ml
Cefuroxime 460 mg Intravenously
Monitor VS q2hrs
Monitor I & O q4hrs

AT THE ER: