Saint Louis University

School of Medicine
Department of Pediatrics

ASUNCION, Erika Antoinette S.

HISTORY
I. GENERAL DATA
This is the case of H.A.D., 12 years old, female, Filipino, single, Roman Catholic, born on
November 19, 2006 at Pines City Doctors’ Hospital, Baguio City. She recides at Bayabas, Pico,
La Trinidad. This is her first hospital admission. She was admitted on August 24, 2019. The
patient is the informant, with a percentage reliability of 90%.

II. CHIEF COMPLAINT

Chief complaint: Fever ranging from 39-40C

III. HISTORY OF PRESENT ILLNESS

One day prior to consult at around 2 pm, the patient was on her way home from school when
she experienced headache localized at her frontal area. From there, she started to have chills and
get dizzy. On the evening of the same day, the patient experienced pain in the hypogastric and
right iliac regions of the abdomen, rated as 5/10 (on a scale of 1-10 with 10 being the greatest
sensation of pain), accompanied by nausea.

On the day of consult at 12 am, the patient took 250 mg of Paracetamol (Biogesic) and
claimed to relieve her headache. Additionally, her grandmother gave her a tepid sponge bath in
an attempt to lower her temperature. That was when her grandmother noticed rash on her back,
chest, and abdomen. At 1 pm, 15 mL Paracetamol (Tempra) was given to her, and consequently
she was brought to the hospital to be admitted. On the way to the hospital, the patient vomited
once.

IV. PAST MEDICAL HISTORY

The patient does not recall any illnesses (mumps, measles, rubella, and chickenpox). There
were no previous admissions and surgeries. She does not have allergies and injuries. She claims
to have been immunized in her early childhood but does not recall the specific vaccinations. She
has never had her menarche.
 V. PERSONAL HISTORY

The patient’s usual diet consists of rice, fish, soup, vegetables, poultry, bread, and biscuits.
She has a preference for meat. She drinks an average of 6L water per day and does not drink
coffee, tea, soda, juice, and avoids eating junk food. She used to have a good appetite prior to the
onset of signs and symptoms. She takes vitamin C 500 mg tablets but not regularly.

VI. FAMILY HISTORY

Both of her parents are alive and well without any disease. Her mother is a housewife and her
father is a businessman, both of which graduated college. The patient is the first child among 3
siblings. The second child is aged 7 and asthmatic, while the third child is aged 6.

VII. SOCIAL ENVIRONMENTAL HISTORY

She is currently a grade 8 student of Star Colleges. She lives with her family in a 2-storey
house with 5 rooms with 8 occupants. There are no exposures to cigarette smoke and pollutants.
Her grandmother has a lot of plants around the house where mosquitos usually hide. Multiple
cases of dengue fever have been reported in the neighborhood in the previous months. Her father
had dengue 4 months ago, and her uncle also had DF 2 months ago. Garbage is segregated and
collected weekly. Toilet facility is a water-sealed toilet. The household’s water source is water
district for domestic use and mineral water for drinking.

VIII. REVIEW OF SYSTEMS

General: (-) Weight loss; (-) weight gain; (-) delay in growth
Cutaneous: (+) Erythematous rash over the back, chest, abdomen, upper and lower extremities;
(-) acne; (+) pruritus
Head: (+) Frontal headache; (+) dizziness; (-) visual difficulties; (-) lacrimation; (-) hearing
difficulties; (-) aural and nasal discharges; (-) epistaxis; (-) salivation and sore throat; (+) globus
sensation when swallowing; (-) clogged nose
Cardiovascular: (-) Orthopnea; (-) cyanosis; (-) fainting; (+) easy fatiguability
Respiratory: (-) Chest pain; (-) cough; (-) difficulty breathing
Gastrointestinal: (+) Episode of vomiting; (-) diarrhea; (+) abdominal pain; (-) jaundice; (+)
decrease in appetite
Endocrine: (-) Breast pain/discharge; (-) palpitations; (-) head and cold intolerance; (-) polyuria;
(-) polydipsia; (-) polyphagia
Nervous and behavioral: (-) Sleep problems; (-) convulsions; (-) paralysis; (-) mental
deteriorations; (-) personality and behavior change; (-) memory loss; (-) school failures; (-) mood
changes and outbursts; (-) hallucinations
GUT: (-) Dysuria; (-) vaginal discharges; (-) itching; (-) urinary frequency; (-) swelling of hands
and feet
Musculoskeletal: (-) Bone pain; (-) joint and muscle pain; (-) swelling in bone, joint, muscle; (-)
limitation of motion; (-) stiffness; (-) limping
Hematopoietic: (-) Pallor; (-) bleeding manifestations; (-) easy bruising
PHYSICAL EXAMINATION
General Patient is generally well with no alarming signs. She has a normal lordotic and
appearance kyphotic posture with decreased rate of motor activity and normal gait. Patient is
dressed appropriately for the weather and is moderately groomed without foul
body or breath odors. Patient is lethargic and has a normal rate of speech. The
patient is conscious, coherent and oriented to time and place and she is not in
cardiopulmonary distress.
Vital signs  CR: 84 bpm
 RR: 18 cpm
 Temp: 38.6C
Anthro-  Height: 5 ft; Weight: 48 kgs
pometric  BMI: 20 kg/m2 (normal)
Skin Fair skin tone and texture with normal skin turgor and maculopapular rashes
present over the ulnar areas of her upper extremities, lower back, lower
abdominal region, and lower extremities (concentrated near the ankles). No
dehydration with capillary refill within 2 seconds.
HEENT Head: Black gray hair distribution with no signs of alopecia. Skull of the patient
is of proportionate size compared to the rest of the body
Eyes: Eyes are aligned properly and have non icteric sclera, pinkish palpebral
conjunctiva
Ears: Normal auricles, canals, and tympanic membrane is intact. No diminished
auditory acuity.
Nose: Nostrils are not clogged and nasal mucosa is moist and pinkish, no sinus
tenderness, nasal turbinates are not congested.
Throat: Pink and moist lips, moist mucosa with non-bleeding gums and cavitied
right molars, premolars and part canine dentition. White scaly plaques present on
tongue. Superficial cervical lymph nodes are enlarged, non-tender and warm to
touch.
Chest and No rashes or abnormal growths on posterior thorax and lower back. Tender T-1
lungs spinous process graded 5/10 on pain scale by the patient, symmetrical chest wall
expansion, with no CVA tenderness. Dull lung percussions with normal
breathing sounds and no adventitious sounds.
Heart PMI at the 5th LICS, MCL, no heaves or thrills, non- tachycardia with regular
rhythm, S1 louder at the apex, S2 louder at the base, no S3 or S4 on lateral
decubitus position, no murmurs, JVP at 2.5 cms
Abdomen Normoactive bowel sounds, no aortic bruit. Tender hypogastric region of
abdomen rated 5/10 on pain scale. Negative hepatojugular reflex
Extremities Symmetrical, complete set of digits, pinkish nailbeds, creases on anterior 2/3 of
plantar surface, capillary refill time less than 2 seconds, full and equal peripheral
pulses
Nervous Pale nails. No rashes or abnormal growths of mass or digits.
system Non tender, non-erythematous, non-enlarged palmar and Interphalangeal joints
without crepitus and no limited range of active and passive movements of the
hands and fingers. Lower extremities showed no abnormal growths of masses or
digits. No pitting edema, symmetric Dorsalis pedis and Posterior tibial pulses.
No varicose veins. No enlarged joints or limitations of movement.