NEW ERA UNIVERSITY

COLLEGE OF MEDICINE

PEDIATRIC HISTORY
QUEZON CITY GENERAL HOSPITAL

SUBMITTED BY:
Orero, Ygierney
Palogan, Hazel
Panopio, Luis Angelo
Pascua, Xymber Zeth Fortu
Pineda, Jon Levin
Reyes, Lovely
Tagufa, Kathlyn Gail
Tuiza, Lejanni
Uy, Rhea Andrea Flores

CMED2: GROUP 3
Date of Interview: November 7, 2019 Informant: Patient and the auntie
History Taken By: CMED2 Reliability: 40%

GENERAL DATA 
K.E, 7 year old Filipino female, Catholic, born on August 22, 2012 at East Avenue Medical Center
and currently residing in Himalayan, Quezon City. Admitted for the first time at Quezon City General
Hospital on November 3, 2019 at 10p.m.

CHIEF COMPLAINT: 
Intermittent low grade fever for 3 days

HISTORY OF PRESENT ILLNESS 

3 days prior to admission, K.E had low grade fever of 38C accompanied with dizziness and
headache at the frontal area, usually in the morning upon waking up. The pain and dizziness eventually
fades througout the day She was given 6ml Paracetamol every 4 hours by his mother for relief, which
lowered her temperature only for a couple of hours and was able to do her usual activity. Loss of appetite
was observed. She only ate half cup of rice with soup instead of 1 cup. Normal urine output and bowel
movement was monitored. No malaise and abdominal pain were present. No vomiting was noted. No
cough and colds were manifested. No consult was done. 
2 days before hospitalization, the patient’s low grade fever persisted as well as her accompanied
signs and symptoms. The same medications were given, 6ml Paracetamol every 4 hours. No other
therapeutic measures were rendered. K.E still had no appetite. Decreased energy and activity started to
develop. Normal urine output and bowel movement was still observed. Vomiting and abdominal pain were
denied by the patient. Patient did not seek consult. 
1 day prior to admission, there was still persistent low grade fever accompanied with headache
and dizziness. The same medications were continued. Body malaise, decreased daily activities and loss
of appetite were noted. Decreased urine output and bowel movement was observed. Vomiting and
abdominal pain were denied. No consultation done.
On the day of admission, the patient developed high grade fever of 39.4C and symptoms
persisted. She was brought to the Quezon City General Hospital at 10:00pm where her temperature was
taken and complete blood count was done, hence admission.

PAST MEDICAL HISTORY

K.E. has no history of measles, mumps, chicken pox, polio, and tetanus. She has known allergies
in eggs and chicken diagnosed at 1 year old by the physician. Her allergies were described to be red or
pale at times due to food intake that appeared first at the face then eventually to the trunk and upper
extremities. She was given antihistamine for relief. The patient has no history of fractures, trauma or
surgery.
At 6 months old the patient had a reaction with milk which her paediatrician diagnosed as lactose
intolerance and was prescribed Enfamil as a breast milk substitute. She presently does not show any
signs and symptoms of lactose intolerance.
The informant stated that K.E had her immunization at East Avenue Medical Center however
dates were unrecalled.

NUTRITION 
 K.E is fond of eating rice with soups especially champorado. The usual meal of the patient during
breakfast is soups, and for lunch and dinner are fish, hotdog and rice. However, she rarely eats
vegetables. K.E frequently drinks water for 3 glasses a day. She is taking CELINE as her daily vitamins.

IMMUNIZATION
The informant stated that K.E had her immunization at East Avenue Medical Center, however
dates were unrecalled. No boosters nor follow up were done.

MEDICATIONS/ ALLERGIES
Patient has known allergies in eggs and chicken. K.E did not undergo any medications apart
from his recent admission.

FAMILY AND GENETIC HISTORY

Patient’s mother, housewife, is alive and well with no known significant disease. K.E’s Father is
currently working as OFW, no known disease noted. The patient has one younger sibling, 3year old, with
healthy condition. On her mother’ side, her grandparents are still alive and well, with no history of
hypertension, stroke and other medical conditions. On her father’s side, grandmother is still alive with no
significant disease. However, the grandfather is deceased due to Cirrhosis.

PERSONAL AND SOCIAL HISTORY 

The patient’s family resides in a bungalow situated beside a creek. There are a total of three
people in one household. The patient’s father is a construction worker and her mother is housewife. The
family’s water source for household comes from Nawasa. They usually buy Mineral water for drinking.
Their garbage is collected twice a week.
The patient is exposed to cigarette smoking because her mother is a smoker. The patient is a
grade 7 student at Pasong Tamo Elementary School. K.E is an aspiring honour student and very active
in school. Her favourite subject is Math. She also has three friends in school.