Informant: Mother

Percent Reliability: 75%

General Data:
O.D 8 y/o, female, Roman Catholic, Filipino, born on February 25, 2014 at Bagong
Silang Quezon city, currently residing in Bagong Silangan admitted for the 4th time in FEU-
NRMF, May 27, 2022.

Chief Complaint: Fever for 8 days

History of Present Illness:

History of present illness started 7 days prior to admission when the patient was noted to
have fever with a maximum temperature of 39.3 C. No associated signs and symptoms like
cough, colds, body malaise, vomiting, loose stools and urinary frequency. The patient had a good
appetite and good activity. The patient took paracetamol 250mg/5ml, 7ml every 6 hours (TD=
10/kg/dose) which provided temporary lysis of fever. No consultation was done at this point
6 days prior to admission, the patient was afebrile but complained of watery based stools
4 times during the day, more than the usual 1-2 times a day. Increase in bathroom visits was
accompanied by generalized crampy, abdominal pain. Still no associated signs and symptoms
like cough, colds, vomiting, loose stools and urinary frequency. The patient had a good appetite
and good activity. No medications were taken, but the patient ate a banana and an apple every
meal which the caregiver believes helps harden the stool. No consultation was done at this point.
During the interim, the patient was well, no fever, no loose stools, no abdominal pain,
with good appetite and activity
4 hours prior to admission, there was a recurrence of fever with a maximum temperature
of 38.3 C. No associated signs and symptoms like cough, colds, abdominal pain, body malaise,
vomiting, loose stools and urinary frequency. The patient took paracetamol 250mg/5mg, 7ml
(TD= 10/kg/dose) which afforded no relief.
Few hours prior to admission due to the persistence of fever, the caregiver decided to
seek consultation, and the patient was subsequently admitted to our institution.

Past Medical History:

- Previous admissions:
- 2015 due to Acute Gastroenteritis, viral
- 2016 due to UTI
- 2017 due to dengue
- With previous history of chicken pox at 4 years of age
- No history of Bronchial Asthma
- No history of surgery and blood transfusion
- No history of TB disease or exposure to suspected patient with TB disease
- No history of seizures or known allergies to food and medication
- No history of heart, thyroid, liver and kidney disease.
- No history of COVID-19 infection
- No history of COVID-19 exposure

Family History:
Mother: 31-year-old, fashion design college graduate, house wife currently 4 months pregnant,
apparently well. With complete COVID 19 vaccine (Pfizer 2 doses, August and September 2021)
Father: 31-year-old, 2nd year college undergrad, bank account specialist, apparently well. With
complete COVID 19 vaccine (Pfizer 2 doses, August and September 2021)
No siblings

Immunization History:
VACCINES DOSE Place Given
BCG 1 dose At lying in, birth
At lying in, birth
Hepatitis B 4 doses
DPT 3 dose Local Health Center

HiB 3 dose

OPV 3 dose

MMR 1 dose

PCV 2 doses

Rabies 1 dose

Nutritional History:
The patient was exclusively breast fed for up to 6 months, mixed feeding was started at 7
months with milk formula (bonakid) up to 9 months. Solid food was introduced at 9 months with
blended food (ex. carrots) and cerelac.
The patient usually eats 1 cup of rice with viand, 3 times a day with snacks in between.

Personal and Social History:

The patient lives with parents and uncle in a well lit well ventilated house. Her father is
the primary financial provider while the mother is her primary caregiver. Water Supply is from
Maynilad. Garbage is segregated and collected thrice a week.

PHYSICAL EXAMINATION

General Survey: Conscious, coherent, not in distress

Vital signs: BP: 110/70 HR: 105bpm RR: 24 cpm T: 36.3 °C O2 sat: 98%

Anthropometric: Ht: 138 cm Wt: 31 kg IBW: 32.4kg BMI: 16.3kg/m2 AC: 59cm

HEENT: Pink palpebral conjunctiva, white sclera, patent ear canal, intact tympanic membrane,
dry lips, moist buccal mucosa, pink pharyngeal walls
NECK: Supple neck, no palpable lymph node,
CHEST/LUNGS: Symmetrical chest expansion, no retractions, good air entry, clear breath
sounds
HEART: Adynamic precordium, normal rate, regular rhythm, no murmur
ABDOMEN: flat, soft abdomen, non tender, with normoactive bowel sounds.
EXTREMITIES: No gross deformities, joints were warm to touch, full and equal pulses,
capillary refill time < 2 seconds
SKIN: smooth and brown.

NEUROLOGIC EXAM:
Cerebrum:  Conscious, coherent
Cranial Nerves:
● I: not assessed
● II, III: Pupils reactive to light
● III, IV, VI: able to follow pen with eyes
● V: can symmetrically open and close mouth
● VII: no facial asymmetry, able to close eyes, can smile
● VIII: intact gross hearing
● IX & X: intact gag reflex, uvula at midline
● XI: can turn head from side to side, can shrug shoulders
● XII: tongue at midline
Signs of meningeal irritation: No nuchal rigidity, no Kernig’s, No brudzinski
Sensory function: 100% sensation on all extremities
Motor function: not assessed
 COURSE IN THE WARD

Upon admission (May 27, 2022), the patient was seen and examined with the following
stable vital signs:  CR of 110, RR of 20, and T of 37°C. No fever, colds, vomiting, loose stools,
abdominal pain, myalgia, bleeding, hematoma. Patient had good appetite and activity. Upon
physical examination, the patient had pink palpebral conjunctiva, white sclera, pink turbinates,
moist lips, pink pharyngeal walls, no rectractions, clear breath sounds, tachycardic, regular
rhythm, no murmur; abdomen is flat, soft, non-tender, normoactive bowel sounds, with  full and
equal and CRT <2 seconds. The patient was placed on a diet as for age. She was hooked to
D5LR to run at 71 cc/hr as full maintenance. The following diagnostic tests were requested with
their corresponding results: CBC with increased WBC (18.42 x 10^9/L),  neutrophils (0.811),
and decreased lymphocyte (0.080). Dengue duo was nonreactive; C-reactive protein of 5.59
mg/L, ESR of 15 mm/hr; Blood culture and sensitivity had no growth after 24 hours  of
incubation, Urinalysis result of negative for the following: blood, bilirubin, ketone, protein,
nitrite, glucose, and leukocytes; Urine culture and sensitivity; Chest X-ray (PA-L) showed clear
lungs, unenlarged heart, and unremarkable diaphragm and bony thorax; COVID-19 RT-PCR,
and Rapid Antigen Test were Negative. Medications were also started: Paracetamol
250mg/15ml, 6.5ml every 4 hours as needed for temperature ≥37.8 C (TD: 10.48ml/kg/dose).
Patient was weighed now then daily.  Vital signs were monitored every 4 hour; Intake and output
were measured every shift.  Watch out for fever, abdominal pain; and refer accordingly. 
On the 2nd hospital day, 9th day of illness (May 28 2022), the patient was seen and
examined conscious, coherent, and hydrated with the following vital signs: CR of 105, RR of
17,  and T of 36.5C. No recurrence of fever, No cough and colds, No abdominal pain and loose
stools  with urine output of 2cc/kg/hr. Patient had a good appetite and activity. Swollen,
Erythematous IV site for reinsertion; warm compress applied on affected area, mupirocin
ointment started TID. IV fluid rate decreased to 36cc/hr.   

On the 3rd hospital day and 10th day of illness (May 29, 2022), the patient was seen and
examined, was conscious, coherent, not in distress, hydrated. The patient was 53 hours afebrile,
with good appetite, with urine output of 1.1 cc/kg/hr.  On physical examination, the patient had
symmetrical chest expansion, no retractions, clear breath sounds, soft, flat abdomen, non-tender,
no mass, no gross deformities, full and equal pulses, CRT <2 seconds. The working assessment
was acute gastroenteritis, viral, rule out sepsis, rule out primary pulmonary tuberculosis. The
plan for this patient is for PPD reading in the morning and sputum AFB smear early morning
twice on the following day. She was prescribed the following home medications: Isoniazid
(Comprilex Forte) 200mg/5ml, give 8ml 30 minutes before breakfast once a day, Zinc gluconate
(Zinbee) 1 tablet 2x a day for 12 more days to complete 14 days, and Colostrum (Pro-Ig) 1
sachet dissolve in small amount of water and drink once a day for 5 days. The patient was
deemed fit for discharge and went home.