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  • Case 1 Group 1

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    Jescel-Anne Janea Magat
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    A 5-year-old male presented with 3 days of fever, body aches, joint pain, and abdominal pain. He was given paracetamol with temporary relief. After 2 more days with nausea and vomiting, he was brought to the hospital. On examination, he was flushed with a temperature of 38.7°C. He had tenderness in his upper right abdomen. His past medical history included varicella, pneumonia, and diarrhea. He was admitted to the infectious disease ward for further evaluation and management.

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    A 5-year-old male presented with 3 days of fever, body aches, joint pain, and abdominal pain. He was given paracetamol with temporary relief. After 2 more days with nausea and vomiting, he was brought to the hospital. On examination, he was flushed with a temperature of 38.7°C. He had tenderness in his upper right abdomen. His past medical history included varicella, pneumonia, and diarrhea. He was admitted to the infectious disease ward for further evaluation and management.

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    6 views3 pages

    Case 1 Group 1

    Uploaded by

    Jescel-Anne Janea Magat
    A 5-year-old male presented with 3 days of fever, body aches, joint pain, and abdominal pain. He was given paracetamol with temporary relief. After 2 more days with nausea and vomiting, he was brought to the hospital. On examination, he was flushed with a temperature of 38.7°C. He had tenderness in his upper right abdomen. His past medical history included varicella, pneumonia, and diarrhea. He was admitted to the infectious disease ward for further evaluation and management.

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    © All Rights Reserved
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    of 3

    Case 1.

    Bed2 Infectious Ward:

    General Data:

    AB 5 year-old, male, Roman Catholic, born on January 26, 2015, presently residing at Mallig,
    Isabela, was admitted on Septemtember 9, 2020 at Cagayan Valley Medical Center.

    Chief Complaint:

    Fever

    History of Present Illness

    3 days PTC patient was noticed to have low to high grade fever, accompanied with body malaise,
    arthralgia, abdominal pain.

    ***TEMPERATURE? PATTERN (CONTINUOUS? REMITTENT? INTERMITTENT?) WHAT TIME OF THE DAY?


    ***LOCATION OF ARTHRALGIA?
    ***ABDOMINAL PAIN? ONSET? LOCATION? DURATION? CHARACTER? AGGRAVATING? RELIEVING?
    TIMING? SEVERITY?
    ***MEDICATIONS TAKEN?
    ***REASON FOR NOT SEEKING CONSULT?

    2 days PTC still with above condition, this time accompanied with nausea and vomiting, no
    seizure noted. Patient was given paracetamol that afforded temporary relief.

    ***TEMPERATURE?
    ***ABDOMINAL PAIN???
    *** ARTHRALGIA??? MYALGIA???
    *** MEDICATIONS DOSE? STOCK DOSE? BRAND? HOW MANY TIMES A DAY?
    ***VOLUME OF VOMIT? HOW MANY TIMES A DAY? TIME OF THE DAY?
    ***REASON FOR NOT SEEKING CONSULT?

    Due to persistence of above condition, patient was brought to nearby health facility that
    subsequently refereed to Cagayan Valley Medical Center for tertiary health care hence his admission.

    Past Medical History

    Patient had history of varicella, pneumonia and diarrhea

    ***HOSPITAL ADMISSION? WHEN?


    ***PRENATAL AND BIRTH HISTORY
    ***NEONATAL HISTORY
    ***POST NEONATAL HISTORY
    ***DEVELOPMENTAL HISTORY
    ***NUTRITIONAL HISTORY
    Immunization History

    Received EPI vaccines

    Growth and Development:

    Appropriate for age


    ***ECONOMIC HISTORY

    Family History

    Father has history of allergy, hypertension.

    Mother has family history of DM, CA and allergy

    Physical Examination:

    General Survey:

    Patient is weak looking, flushed skin

    Vital Signs:

    CR 112, RR 224, TEMP 38.7, weight 20kg

    Skin

    Flushed skin, no rashes, warm to touch

    HEENT

    No sunken eyeball, no naso-aural discharge, dry lips, moistmucosa, no lymphadenopathy noted

    Chest and Lungs

    Symmetrical chest expansion, clear breath sounds

    Heart

    Adynamic precordium, no murmur noted

    Abdomen

    Globular, normoactive bowelsounds, tenderness at right upper and epigastric area

    Extremities

    Grossly normal, bounding pulses for all peripheral pulses

    Genitalia
    Grossly normal male,

    Neurologic Exam

    Neurologic Examination

    CN1

    CN2

    CN3

    CN4

    CN5

    CN6

    CN7

    CN8

    CN9

    CN10

    CN11

    CN12

    Motor

    Sensory

    Meningeal signs

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