PERSONAL INFORMATION

Name JKL
Age 9 years and 6 months old
Birth Date September 17, 2010
Birth Place Nueva Vizcaya Provincial Hospital
Address Santo Domingo, Bambang, Nueva Vizcaya
Gender Female
Blood Type O+
Nationality Filipino
Primary Languages Ilocano, Tagalog
Religion Born Again
Type of family Nuclear Family
Primary Source of Health Care Nueva Vizcaya Provincial Hospital
Services
Primary Source of Health Philhealth member
related to illness
Financial resources Father is a welder, and earns 500 pesos per
day
Significant Others Jenny Ane
Age 26 years old
Address Santo Domingo, Bambang, Nueva Vizcaya
Occupation Housewife
Relationship to Patient Mother

Significant Others Roel

Age 26 years old
Address Santo Domingo, Bambang, Nueva Vizcaya
Occupation Welder
Relationship to Patient Father

PAST HEALTH HISTORY

Baby JKL is the 1st child of mr. and mrs. L and was born on the 9 th month of pregnancy at
the Nueva Vizcaya Provincial Hospital on normal spontaneous delivery and has no complication.
During pregnancy there was no problem that exists, but when the mother gave birth the baby,
they noticed that there are problem, wherein the baby is jaundice, thin, small and the weight is
1.8 kls which means it is low.

The mother stays at home, a housewife, to take care of her baby, and fed through
breastfeeding and bottle feeding until 2 years old of age, and they start giving solid food when
the child reaches her 1 year old. Pumpkin was the 1 st solid food they gave. The child wanted
frozen foods like tocino and hotdogs which is not suitable and there is no nutrients/substance that
can get to nourish her health. Her favorite vegetable is beans and doesn’t like bitter gourd. About
foods the child is very choosy that’s why the child suffered some illnesses. Following;

The child experienced asthma when reaches her 1 year old of age. They take medications
like salbutamol, and position the child on fowler’s position to nebulized, while sleeping the
child’s position is in supine, but the child was not engage in any hard activities. And mostly the
child suffering from diarrhea during summer, wherein it is more frequently during the warm
season and they take medication through giving oresol, also suffers from normal cough, colds,
head ache, fever and they usually gave time to rest, drinking plenty of water and take medicine
like paracetamol syrup that is suitable to her age.

PRESENT HEALTH HISTORY

Patient Jkl is 9 year old, female and was admitted to the hospital and has a chief
complaint of on and off fever for 2 days duration. The child was pale, dehydrated, and weak
during the interview.

It was March 4 when the child is still on a good condition. The child started studying at 8
am to 3 pm. wherein, the distance of their house to the school was not too far, so the child walks
to get in the school, and possibly the child was bitten by a mosquito and resulted to dengue. And
after schooling they played at the house together with other playmates. During weekends, they
like to go to the farm/field and they play “bahay-bahayan” whether they are in the area, full of
mosquitoes and grassy around them. After arriving at their house they did not contented yet, they
play again, basketball with her cousins. At their house, there is poultry of chicken and ducks in
their surroundings, in which there are containers full of some stagnant water in their cages that
the mosquitoes live.

There is a 10 meter away canal from their house which suspected to have a lot of
mosquitoes also.

When sleeping the family is using a mosquito net. In their community JKL is the first
case recorded to have a dengue fever.

On March 5, afternoon, the mother noticed that her child has no energy, and has no
appetite, and does have a head ache, with a pain scale of 1 out of 10, 1 is the mildest and 10 is
the most severe, the intensity is 6. No thermometer was available, touch by skin, by putting her
palm to check the child’s temperature, and it was found out that it was too high. Jkl has fever on
the same day; also her skin is too sensitive. Little bump on anything, bruises appeared
immediately. And noticed that rashes where seen upon inspection. The parents decided to give
her a medication which is paracetamol syrup and instruct to drink a lot of water, and take her to
rest. The fever was gone for a while until morning march 6, but on the afternoon, it was back, the
mother noticed there is a pint of blood on the nose of her child. Then they decided to run
immediately JKL to the hospital. The admitting diagnosis is Dengue Hemorrhagic Fever. Same
day, 3:55 pm, the patient have undergone hematology test and the result is 61x10^9/L and it was
found out that her platelet is too low.

FAMILIAL HISTORY
The family has a genetic problem; the sister of JKL who is the second child of their
family, and currently living with them was diagnosed at Nueva Vizcaya Provincial Hospital with
G6PD and is strongly believe that is was hereditary disease transmitted or passed by their
generation from her father’s side. The mother stated also that sister of her husband which is the
tita of JKL is diagnosed with the same disorder. As for the other members of the family, her
grandmother has a high blood pressure.

SOCIO ECONOMIC STATUS

 Currently Mrs. L has no job and is a housewife. Her husband is a welder in Bambang,
Nueva Vizcaya and is earning 500 pesos per day, his day off is every Saturday and Sunday (P11,
000/month).