Name: Godwin Manallo Hospital: DLSUMC

Informant: Mrs. Manallo (mother) Department: Pediatrics

Reliability: 100% Preceptor: Dr. K. Santos
Historian: Crizza Mae S. Garcia Date Taken: July 15, 2019
Group: 6B Date Submitted: July 18, 2019

CLINICAL HISTORY
I. GENERAL DATA
G.W., 7 years old, born on July 15, 2012 at Dasmarinas City, Cavite, male, Filipino, Roman Catholic, presently residing
at Dasmarinas City, Cavite, was admitted for the first time at De La Salle University Medical Center last July 9, 2019.
Informant is the patient’s mother, with a 100% reliability,

II. CHIEF COMPLAINT

High fever for 3 days

III. HISTORY OF PRESENT ILLNESS

The patient was apparently well until about two days prior to admission when the patient first started exhibiting high
fever of 39.6°C and loss of appetite. He was given Paracetamol syrup (Calpol, 15 mL) during high temperature readings.
His fever was relieved temporarily but recurs.

One day prior to admission, the patient’s fever progressed to 40.5°C, and has experienced dizziness during periods of
high fever and vomiting of about 3 cups of watery consistency. His medication continued but has given him still only
temporary relief.

The progression of fever and the appearance of other symptoms have prompted the patient’s mother to seek consult at
DLSUMC – ER and for the patient to be admitted to the pediatric ward on July 9, 2019.

IV. REVIEW OF SYSTEMS

General (+) loss of appetite, (-) weight loss/gain, (-) poor activity, (-) delay in growth
Skin (-) rash, (-) pigmentation, (-) hair loss, (-) acne, (-) pruritus
Head-Eyes-Ears-Nose (+) headache, (+) dizziness, (+) colds, (+) nasal discharge, (-) epistaxis,
(-) vision difficulties, (-) use of glasses, (-) lacrimation, (-) hearing difficulties,
(-) ear pain/discharge
Neck and Throat (+) mass, (+) sore throat, (+) dysphagia, (+) odynophagia, (-) lymphadenopathy,
(-) muscle stiffness
Cardiovascular (-) cyanosis, (-) orthopnea, (-) fainting spells, (-) easy fatiguability, (-) palpitation
Respiratory (+) cough, (+) dyspnea, (+) sleep apnea, (-) chest pain
Gastrointestinal (+) vomiting, (-) diarrhea, (-) abdominal pain, (-) constipation, (-) encopresis, (-) jaundice,
(-) food intolerance, (-) passage of worms
Genitourinary (-) dysuria, (-) frequency, (-) discharge, (-) enuresis, (-) edema
Endocrine (+) heat intolerance, (-) cold intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia
Nervous/Behavioral (-) temper outbursts, (-) seizures, (-) eating problems, (-) weakness, (-) mood changes,
(-) sleep problems, (-) behavioral/personality changes, (-) memory loss, (-) hallucinations
Musculoskeletal (-) myalgia, (-) joint pains, (-) swelling, (-) limping, (-) limitation of motion
Hematopoietic (-) pallor, (-) bleeding, (-) easy bruisability

V. BIRTH AND MATERNAL HISTORY

Prenatal
The patient’s mother was 28 years old during conception with an OB score of G3P2 (2012). The patient’s father was 35
years old. The patient was the third to be conceived and was a planned pregnancy. The mother could not recall the
exact number of prenatal consults but reported that she consulted regularly, had no maternal illnesses, was not
hospitalized and was not exposed to teratogens or substances during its course. She was given ferrous sulfate and folic
acid during her pregnancy and was requested for laboratory workups such as ultrasound, CBC, amniocentesis,
urinalysis and OGCT/OGTT with normal results.

Perinatal
The patient’s mother underwent 11 hours of labor and was given epidural anesthesia. There were no complications
during labor.

Postnatal
The patient’s mother completed a term pregnancy of 37 weeks AOG. She underwent normal vaginal delivery and had
an uneventful delivery with no complications. The patient was delivered at a hospital in Dasmarinas City, Cavite and
was attended by a doctor. The patient’s mother could not recall the patient’s birth weight and length, as well as other
anthropological measurements at birth. The patient’s APGAR score is 9/10, had no problems post-delivery, and was
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not admitted to the NICU. Newborn screening was done and was normal while hearing screening and eye/retinal
examination were not performed.

VI. PAST MEDICAL HISTORY

The patient had no history of recurrent high fever, no history of illnesses such as measles, mumps, chicken pox, asthma
and allergy, was not hospitalized nor had any operations or surgeries prior to admission and is currently taking Ascorbic
acid (Ceelin Chewable Tablets, 100 mg) for supplementation.

VII. FAMILY HISTORY

The patient’s grandfather had a history of diabetes, while both his grandparents had a history of hypertension. No similar
illness experienced by the patient and other heredofamilial illness such as allergy/atopy, asthma, behavior and emotional
problems, and congenital and developmental disorders were present in the patient’s family.

VIII. NUTRITIONAL HISTORY

The patient is formula-fed from birth until 1 year old, was started on complementary feeding when he was 7 months old,
has good appetite and is fed with table food three times a day with snacks in between. The patient is not a picky eater
in general but is a selective eater in terms of vegetables. No food intolerance or feeding difficulties were reported.

IX. IMMUNIZATION HISTORY

The patient received a complete immunization history of the following vaccines with no complications noted.
Number of Reactions and
Doses Complications
BCG 1 None noted
Hepatitis B 1 None noted
Penta Vaccine 3 None noted
(DPT, Hepa B, HiB)
OPV 3 None noted
Measles 1 None noted
MMR 1 None noted
Rotavirus 2 None noted

X. DEVELOPMENTAL HISTORY
The patient’s skill in all domains of development were appropriate for his current age of 7.

XI. PERSONAL AND SOCIAL HISTORY

The patient’s mother is a 34-year-old housewife, while his father is a 48-year -old seafarer. Both are the biological
parents of the patient, are married, and lives along with the patient’s two other siblings. The patient is the youngest of
the three children. His primary caretaker is his mother. He was introduced to the use of TV and cellphones by the age
of 3 to 4 years old and uses it at least 3 accumulated hours daily.

XII. ENVIRONMENTAL HISTORY

The patient lives at an area that does not expose him to second-hand smoke or other substances. The family drinks
purified water and uses tap water for self-cleaning. Garbage collection around their area occurs at least once a week.
Toilet waste disposal is through a septic tank.

PHYSICAL EXAMINATION
A. GENERAL SURVEY
The patient is well-developed, well-nourished, conscious, coherent, ambulatory, oriented to time, place and person, in
no cardiorespiratory distress, and appears his chronological age of 7.

B. VITAL SIGNS
Blood pressure 90/60 mmHg, supine
Heart rate 100 beats per minute
Pulse rate Not taken
Respiratory rate 21 cycles per minute
Temperature 35.9°C

The patient is normotensive, with full, equal and regular rhythm and rate of pulses, in no respiratory distress and is
normothermic.

C. ANTHROPOMETRIC DATA
Weight 49 kg
Height 126 cm
BMI 30.81

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D. GROWTH CHART CLASSIFICATION
Weight for age Above 3 (+3)
Height for age Above 1 (+1)
BMI for age Above 3 (+3)

The weight for age and BMI for age suggests that the patient is obese, while the height for age suggests the patient has
no stunted growth.

E. EXAMINATION OF THE SKIN

The patient is fair, with injection site bruise at the left arm, with no pallor, jaundice, erythema or hyperpigmentation and
edema. Temperature is afebrile to touch, with prompt return of skin upon skin turgor. The patient’s skin is well-
moisturized, with no hair loss or excess, no nail plate deformity or dystrophies, no change in shape, color, nail fold
lesions nor tenderness and good capillary refill.

F. EXAMINATION OF THE HEAD AND NECK, EYES, EARS, NOSE AND THROAT
Head and Neck
The patient’s hair is black and of normal pattern, texture, no hair loss or excess. The scalp and head is symmetrical,
with no masses or tenderness. The face is normal with symmetrical movement, with no masses or tenderness. The
parotid and submandibular glands are not enlarged, with no masses nor tenderness.

The patient’s neck is in midline position, with no deformities, swelling or hyperpigmentation, with no apparent masses
or tender lymph nodes.

Eyes
The eyes are symmetrical in relation to the face and aligned with each other. The eyebrows are normal in quality and
distribution. The eyelids are in normal position, adequately closes, with no edema or lesion. The conjunctiva is pink,
sclera white with non-prominent blood vessels, devoid of nodules of swelling. Pupil is 2-3 mm, briskly reactive to light.

Ear
The ears are aligned with each other and is symmetrical in relation to the face. Pinna and periauricular areas are free
of masses, swelling or ulceration. The ear canal is free from obstruction and discharge on both ears. Tympanic
membrane intact, pearly gray, shiny and translucent.

Nose
Nasal septum is in midline, external nose symmetrical, aligned vertically in the midline, free of any masses, deformities
or tenderness. External nares equal in size and shape. Nasal cavities present and devoid of masses, ulceration or
discharge.

Oral Cavity and Oropharynx

Lips are symmetrical, pinkish, devoid of masses or ulcerations. Oral mucosa and gums are smooth, pinkish, free of
lesions, masses or ulcerations. There is dental caries on the teeth. The tongue is mobile, with dorsum pink and free of
masses or ulcerations. The palatine tonsils are enlarged, uvula and palate rise symmetrically. There is a mass on the
right side of the pharynx, measuring about 3 mm bigger than a green pea.

G. EXAMINATION OF THE CHEST AND LUNGS

There is a regular breathing pattern, with AP: Transverse diameter of 1:2, with symmetrical chest expansion. There is
equal bronchial and bronchovesicular breath sound, with wheezes on the upper lung fields, and no crackles or other
adventitious sounds.

H. EXAMINATION OF THE CARDIOVASCULAR SYSTEM

There is no precordial bulge. PMI and apex beat at the 4th ICS left midclavicular line. No heaves, thrills, with normal rate
and regular rhythm. S1>S2 on the apex, S2>S1 on the base, no murmurs.

I. EXAMINATION OF THE ABDOMEN

The abdomen is globular and symmetrical. With no scars, abnormal discoloration, visible mass, peristalsis or everted
umbilicus.. The abdomen has 7 bowel sounds per minute, with no bruits nor friction rub. The abdomen is soft and is
non-tender.

J. EXAMINATION OF THE GENITALIA, ANUS AND RECTUM

Examination of the genitalia, anus and rectum were not performed.

K. EXAMINATION OF THE EXTREMITIES

There are no joint pains, and difficulty dressing and walking. The gait is normal with no redness, masses, swelling,
dislocation or atrophy in the joints. There is also no limitation of motion in the upper and lower extremities.

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L. NEUROLOGIC EXAMINATION
Mental Status Examination
The patient is awake, acts and dresses accordingly to his age and sex, uses proper language and has normal speech.
He is slightly irritable but with an appropriate affect, is unresponsive to questions but is able to comprehend, and is
uncooperative with the examiners.

Cranial Nerve Examination

Cranial Nerve Findings
I Patient did not cooperate and was fixated on his phone.
V Sharp and blunt sensation was felt equally on both sides of the face
(+) Corneal reflex
VII No facial asymmetry
Was able to perform different facial expression
Able to puff out cheeks
IX, X Good speech and palatal sounds “kakaka”
Palatal elevation “ah ah ah”
(+) Gag reflex
Able to swallow
Midline uvular position
XI Good trapezius and sternocleidomastoid contraction
Shoulder shrugging and head movements
XII Lingual articulation “la la la”
Tongue protrusion
Lateral movement
(-) tongue atrophy
(-) fasciculations

Somatic Motor System Somatic Sensory System

Muscle strength (5/5

CASE DISCUSSION
A. SUMMARY OF CLINICAL DATA
The patient is a 7-year-old obese male admitted to DLSUMC due to continuously high fever for three days ranging from
39°C to 40°C. The fever was accompanied with loss of appetite, vomiting of watery consistency, and headache and
dizziness related to increase in body temperature. He was given Paracetamol syrup (15mg) but was not relieved. Other
symptoms noted were dysphagia, odynophagia and cough and colds on his third day on the hospital. The patient was
noted to have sleep apnea and a mass on the right side of the throat measuring about 3mm larger than a green pea.
Upon further physical examination, it was also noted that there is an inflammation of the tonsillopharyngeal wall with no
exudation.

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B. DIAGNOSIS
The most likely diagnosis for the case is dengue fever (non-specific febrile illness) with concurrent acute tonsillitis. The
most telling reason as to why it led to this diagnosis was because of the patient’s continuously high fever, vomiting, loss
of appetite, sore throat and other signs and symptoms which were ruled in on the table below.

DIFFERENTIAL DIAGNOSES
Rule IN Rule OUT
Dengue fever • High fever • Retro-orbital pain
• Nausea and vomiting • General body pain
• Sore throat • Rash
• Headache • Weakness
• Anorexia • Mild hemorrhagic manifestations
Acute tonsillitis • Fever • Foul breath
• Sore throat • Tender cervical lymph nodes
• Dysphagia
• Odynophagia
Influenza • Fever • Myalgias
• Sore throat • Frontal or retro-orbital headache
• Nasal discharge • Weakness and severe fatigue
• Cough and other respiratory symptoms • Tachycardia
• Red, watery eyes

Dengue fever – non-specific febrile illness

Dengue is one of the most common and important arthropod-borne viral illness in humans transmitted by mosquitoes
of the genus Aedes, which are widely distributed in the subtropical and tropical areas of the world such as the Philippines.
Dengue epidemics closely follow seasonal climatic change with waves of epidemics following each rainy season. One
of the major risk factors of acquiring dengue is living in endemic areas of the tropics where the mosquito thrives.
Recently, the Department of Health recently declared National Dengue Alert and is monitoring the patient’s residence,
CALABARZON.

Acute tonsillitis
Tonsillitis is the inflammation of the pharyngeal tonsils. Viral or bacterial infections and immunologic factors lead to
tonsillitis and its complications. This disease most often occurs in children and is caused by Streptococcus species in
children aged 5-15 years old. School-age children are more commonly involved because the bacteria tends to get
passed on schools where children are in close proximity. The patient, in this case, is a school-age child and probably
contacted the bacteria from his peers.

Influenza
Influenza, one of the most common infectious diseases, is a highly contagious airborne disease that occurs in seasonal
epidemics and manifests as an acute febrile illness with variable degrees of systemic symptoms.

PLAN OF MANAGEMENT
A. DIAGNOSTICS
Dengue Fever (non-specific febrile illness)
1. Complete blood count with differential count. Useful for looking for trend of the number of WBC, platelet and
hematocrit, which are indicators of the prognosis and appropriate treatment for the patient.
o An increase in hematocrit above baseline and drop in platelet count is an indicator the patient is at risk of
entering critical phase of the disease.
2. Dengue NS1 Antigen rapid screening test. Useful for the detection of dengue virus. It is an
immunochromatographic assay for the rapid detection of dengue virus NS1 antigen in human blood. It has up
to 97% sensitivity and 100% specificity.
3. Polymerase chain reaction. Gold standard laboratory test to confirm dengue virus but is only available in dengue
sub-national and national reference laboratories.

Acute Tonsillitis
Acute tonsillitis is usually clinically diagnosed, but if the case warrants diagnostic testing, the following may be done.
1. Throat swab. This is used to determine the whether the cause of tonsillitis is viral or bacterial.

B. THERAPEUTICS
Dengue Fever (non-specific febrile illness)
Treatment for dengue fever is usually supportive and is focused on the relief of symptoms. For the patient, the following
treatment are suggested:
1. Rest. An adequate rest is needed by the patient’s body to be able to fully recover.

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 2. Fluid therapy. This type of supportive management is useful especially in the patient’s case since he has
symptoms of vomiting.
o According to WHO, fluids must be administered orally as much as possible, and intravenous
supplementation necessary if the patient is not able to take fluids orally.
o The recommended first-line intravenous fluid is crystalloids such as (0.9% saline)
3. Paracetamol. For the relief and treatment of patient’s high fever.

Acute tonsillitis
1. Antibiotics. For the treatment of sore throat, one of the patient’s symptoms.
2. Since the patient also exhibits with a mass at the tonsillar area, surgery may also be helpful since the mass
could be the probable cause of the patient’s sleep apnea.

C. DISCHARGE
1. Absence of fever for at least 24 hours without the use of anti-pyretic
2. Return of appetite
3. Visible clinical improvement
4. Good urine output
5. No respiratory distress
6. Platelet count of more than 50,000/mm 3

REFERENCES
Department of Health, Philippines. (2019). Dengue Prevention and Control Program. Retrieved July 17, 2019 from
https://www.doh.gov.ph/national-dengue-prevention-and-control-program
National Vector Borne Disease Control Programme (NVBDCP). (2019). Do’s and Don’ts for Managing Dengue
Fever/Dengue Haemorrhagic Fever Cases [PDF]. Retrieved July 17, 2019 from
https://nvbdcp.gov.in/Doc/guidelines%20for%20treatment%20of%20Dengue.pdf
Nguyen, H.H. (2019). Influenza. Retrieved July 17, 2019 from https://emedicine.medscape.com/article/219557-
overview#a1
Rajapakse S, Rodrigo C, Rajapakse A. Treatment of dengue fever. Infect Drug Resist. 2012;5:103–112.
doi:10.2147/IDR.S22613
Shah, U.K. (2018). Tonsillitis and Peritonsillar Abscess. Retrieved July 17, 2019 from
https://emedicine.medscape.com/article/871977-overview#a1
Smith, D.S. (2019). Dengue. Retrieved July 17, 2019 from https://emedicine.medscape.com/article/215840-
overview#a1