AGO GENERAL

HOSPITAL
January 6-10, 2022 ADMISSION
IDENTIFYING DATA:

◦ Name: R. Z

◦ Age: 3

◦ Sex: Male

◦ Address: Brgy. 59, Puro, Legazpi City

◦ Birthdate: 11/29/2018

◦ Religion: Roman Catholic

◦ Nationality: Filipino

◦ Mother: Housewife

◦ Father: Government Employee

◦ Informant: Mother

◦ Reliability: 98%
CHIEF COMPLAINT:

FEVER x 4 DAYS
HISTORY OF PRESENT ILLNESS

◦ 4 days PTA patient was noted to have on and off fever with temperature reaching 39.4˚ and subsides in
the morning.
◦ Few hours PTA patient was brought to a pediatrician and was advised for labs, results revealed low
platelet count and positive for dengue antigen test (NS1) and was advised for admission at hospital of
choice.
PAST MEDICAL HISTORY

◦ (-) Allergy

◦ (-) Previous Hospitalisations

◦ (-) Congenital Diseases

MATERNAL AND OBSTETRIC HISTORY
◦ Patient was born to a 25 year old G1P0

◦ Mother had regular prenatal check-ups

◦ Consistently drank multivitamins and advised supplements during pregnancy

BIRTHING AND NEONATAL HISTORY
◦ Patient was born via normal spontaneous vaginal delivery

◦ Baby was noted to have good cry and good motor activity

◦ No history of neonatal jaundice

◦ Newborn screening was done and yielded negative result

FEEDING HISTORY
◦ Patient was exclusively breastfed for up to 5 months

◦ Started introducing soft baby food after 5th month of exclusive breastfeeding

◦ Solid food at 9 months

FAMILY HISTORY:

◦ Both mother and father have no history of comorbidities in respective families

PERSONAL AND SOCIAL HISTORY
◦ Lives with parents

◦ Total of 3 member in the family

ENVIRONMENTAL HISTORY

o Lives near legazpi boulevard

o There are areas that have accumulation of water from tires on
roofs of other houses as weights against strong winds and
ditches and drains that are blocked by accumulation of trash
o Drinking water is mineral water and “nawasa” for other
purposes
o Cooks via gas range
o Trash is segregated and collected by garbage truckers
GROWTH AND DEVELOPMENTAL HISTORY
◦ Patient is generally curious and playful in their home and likes to watch childrens tv show

◦ Patient knows how to ride his tricycle and can climb stairs on his own

◦ Patient can button and unbutton partially his clothes and undress himself on his own

◦ Patient is also very talkative and likes to converse with mother about the shows he watches or things he observes outside
IMMUNIZATION HISTORY

◦ Patient is up-to-date with his vaccinations

Vaccination schedule
Vaccine Weeks
0 2 4 6 8 9 10 12 14 16 18 20 22

BCG BCG

HEP HEP HEP B HEP B

B B
(DtwP DTwP*/DTaP DTwP*/DTaP
-Hib-
HepB
) and Hib*
other Hib*
DTaP
combi
nation
s

IPV/ OPV*/IPV OPV*/IPV

OPV
PCV PCV* PCV*
Vaccination schedule
Vaccine Weeks
0 2 4 6 8 9 10 12 14 16 18 20 22

BCG BCG

HEP B HEP B HEP B

(DtwP DTwP*/DTaP
-Hib-
HepB)
and
other
DTaPc
ombin Hib*
ations
IPV/ OPV*/IPV
OPV
PCV PCV*
Vaccination schedule
Vaccine Weeks
0 2 4 6 8 9 10 12 14 16 18 20 22

RV RV
Vaccine Months
6 8 10 12 14 16 18 20

HEP B HEP B HEP B(booster)

PCV* PCV* PCV*(booster)

RV RV

Influenza Influenza yearly

Measles Measles

JEV JEV

MMR MMR

Varicella VARICELLA

Inactivated Inactivated Hep A

Hep A
Live Hep A Live Hep A
Vaccine Years
1-3
HEP B HEP B(booster)
PCV PCV*(booster)
iNFLUENZA Influenza
JEV JEV
MMR MMR
VARICELLA Varicella
INACTIVATED Inactivated hep A (booster)
HEP A
LIVE HEP A Live hep A
 REVIEW OF SYSTEMS
General Survey (-) recent weight changes

Skin (-) lesions or rash, (-) pruritus or skin diseases, (-) drying of skin

Heent (-) headache (-) eye pain (-) ear discharge (-) colds (-) nosebleeds (-) bleeding gums

CNS (-) loss of consciousness (-) seizure

Cardiovascular (-) easy fatigability

Respiratory (-) shortness of breath (-) cough

Gastrointestinal (-) abdominal pain (-) diarrhea

Genitourinary (-) crying while urinating (-) changes in color of urine

Hematologic/Lymphatic (-) easy bruising

Neurologic (-) weakness (-) paralysis

 PHYSICAL EXAMINATION
COMPONENTS DATA GIVEN
General Survey Awake, nervous, not in cardiopulmonary distress.

Vital Signs • BP: 80/60

• CR: 73
• RR: 30
• Temp: 36.5
• O2 sat: 97%
• Wt: 12kg

Skin (-) rashes (-) dry skin

Heent • Head: Normocephalic with no facial edema

• Eyes: Anicteric Sclerae, pink palpebral conjunctiva (-) discharge
• Ears: (-) external ear discharge and tenderness
• Nose: Septum is midline (-) discharge (-) bleeding
• Throat (mouth and pharynx): (-) bleeding gums (-) dry mouth, tongue is midline

Chest and Lungs Symmetric chest expansion, (-) Retraction, clear breath sounds upon auscultation

Cardiovascular Adynamic Precordium, (-) murmur

Abdomen Soft, non-tender (-) palpable mass

Extremities No edema, Full pulse, CRT less than 2 seconds

Genito-Urinary System Unremarkable

Neurological examination Patiebt was awake and alert. No signs or neurological deficit noted
 Differential Diagnosis
Differentials RULE-IN RULE OUT
Dengue • Fever • Cannot be ruled out
• Body malaise
• Headache
• Joint pain
• Muscle pain
• Nausea and Vomiting
• Positive Antigen Test

Influenza • Fever • No muscle pain

• Body malaise
• Headache • No join pain
• Nausea and Vomiting • No petechiae

Chikungunya • Fever • Positive for Dengue

• Body malaise
• Joint pain Antigen Test
• Muscle Pain
• Nausea and Vomiting
REVIEW OF LABORATORY RESULTS
CLINICAL IMPRESSION

◦ DENGUE
DISCUSSION
◦ Dengue is a mosquito-borne viral disease that has rapidly spread to all regions of WHO in recent years. Dengue virus is transmitted by
female mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae. albopictus. These mosquitoes are also vectors of
chikungunya, yellow fever and Zika viruses. Dengue is widespread throughout the tropics, with local variations in risk influenced
by climate parameters as well as social and environmental factors.

◦ It causes a wide spectrum of disease. This can range from subclinical disease (people may not know they are even infected) to severe
flu-like symptoms in those infected. Although less common, some people develop severe dengue, which can be any number of
complications associated with severe bleeding, organ impairment and/or plasma leakage. Severe dengue has a higher risk of death
when not managed appropriately.

◦ Dengue is caused by a virus of the Flaviviridae family and there are four distinct, but closely related, serotypes of the virus that cause
dengue (DENV-1, DENV-2, DENV-3 and DENV-4). Recovery from infection is believed to provide lifelong immunity against that
serotype.
PATHOGENESIS
CLINICAL SYNDROMES
MANAGEMENT
 ◦ January 7, 2022
 Patient was admitted under the service of Dr. Ludovice
 Secured consent for admission and management
 IVF: PNSS 1l x 40cc/h
 Diet: for Age, avoid dark colored foods
 Dx:
 COVID RAT, CBC tom 6am
 Medications:
 Paracetamol 120mg TIV Q4 PRN for temp >37.8
 AP informed of admission

COURSE IN 


Relay lab results to AP once available
VS Q4 then record

THE WARD 


WOF: bleeding
Refer accordingly

o January 8, 2022
 IVF to follow: PNSS 1L at 4gtts/min
 Repeat CBC platelet in Am

o January 9, 2022
 IVF to continue then discontinue
 May go home anytime