CASE NOTES

Medical Diagnosis: Dengue Fever

 Litel Ghorl is a 6-year-old girl who lives in Gerona, Tarlac.

 Her mother is a grade 4 teacher in Mababanaba Elementary School.
 She was born in Tarlac on August 30, 2014.
 Her mother rushed her to the ER due to intermittent fever of 39 degrees Celsius for the past 3 days
 Her mother administered paracetamol for three consecutive days, but inspite of the medication, fever
persisted.
 Litel Ghorl was admitted as per the advice of her doctor, Dra. Magaling Magpagaling.
 Litel Ghorl has had pneumonia when she was 2 y/o and had been admitted and stayed in the hospital
for 1 and a half month, mother said, she took amoxicillin as prescribed.
 Mother said, they do not have any family history of any illnesses.
 Litel Ghorl is the only child of Mrs. Mader Ghorl.
 As per the mother, Litel Ghorl loves to play computer games at home but she’s doing her homework
first before playing games, patient also plays outside their house with her friends.
 Litel Ghorl had completed her immunizations when she was a child (DPT, OPV, Hep vaccines, Anti-
measles and BCG) – Barangay Health Center
 No allergies to food, dust, drugs.
 Mother makes herbal oregano juice with calamansi extract when Litel Ghorl catches cold and cough (at
home)
 Litel Ghorl was able to write her name and is also able to read paragraphs. Can tie shoelaces, can also
shade coloring books with minimal error, can fold and cut paper into simple shapes.
 Litel Ghorl loves to eat processed foods such as tocino, meatloaf, hotdog, she seldom eats vegetables
and drinks 6-8 glasses of water.
 Urinates 3x a day and defecates once a day, usually defecates in the morning before going to school.
 Can comprehend and respond accordingly.
 Goes to church with parents every Sunday.
PHYSICAL ASSESSMENT

 Rash present in the right foot, capillary refill 2-3 seconds (the rest are normal)
DIAGNOSTICS
HEMATOLOGY (September 2)

 WBC: 3.0
 RBC: 4.8
 Hgb: 130
 Hct: 0.41
 Platelet: 167
 WBC Differential Count
 Segmenters: 0.85
 Lymphocytes: 0.13
 Monocytes: 0.02
DENGUE NS1 (sept 2)

 Result: positive (+)

URINALYSIS (Sept 3)

CBC with Platelet count (Sept 4)

CBC with Platelet (Sept 5)

Hospital Confinement:

 Acetaminophen 325 mg PO q4-6hr

 Plain NSS 1L to be infused for 8 hours
 dengue vaccine