CASE

C.A. 13, F, QC
CC: DOB

HOPI:
5 months PTA, px had undocumented fever, easy fatigability, and occassional DOB. Px still has good appetite &
activity, hence no consultation/medications given.

2 months PTA, d/t the persistence of S/Sx, consult was done in a local hospital where the assessment was
pneumonia. She was started on Cefalexin for 1 week, however no relief for 3 days hence brought to a private clinic
where dengue test was positive and was then referred to a tertiary hospital.

E
Px was admitted at the hospital and initially managed as a case of dengue howeever she complained of flank pain

M
and an abdominal UTZ was done. No abnormalities where noted in the abdominal UTZ. Px was sent home.

RO
1 month PTA. Px has DOB and prefers to sit d/t easy fatigability. She had undocumented fever and her symptoms
progressed thus consult was made to a private doctor where she was given Clarithromycin for 1 week. Hoeever, she
was noted to have fast breathing thus she was again admitted to the tertiary hospital.

D
ROS:
(+) weight loss

YN
(+) decrease appetite and activity
No changes in bowel habit, no hematemesis, no constipation, no melena, no hematochezia
No hematuria, no oliguria
No polyphagia and no polydipsia
AS
Family Hx:
M
IG
ST
EO
G

Birth and Maternal Hx:

Px is born term to a 24-year-old G1P1(100) nonsmoker, non-alcoholic bevarage drinker with regular prenatal care
check-up in a local health center starting at 4 months AOG. She took in ferrous sulfate and multivitamins. UTZ was
done at 6 months of pregnancy and results where considered normal.
There was no exposure to viral exanthems, radtiation, smoke or vectors.

Px was delivered full-term via NSD assisted by a midwife at home with good cry and activity. There was no cyanosis,
pallor, jaundice, cord coil, meconium stained amniotic fluid, with unrecalled birth weight.
Routine NB care was rendered upon delivery. Px was given vitamin K and BCG and had NB Screening done –
Normal. Hearing screening was note done. Patient passed stools and urine within her 24 hours of life.
Nutritional Hx:
Px was breastfed until 6 months. Complementary feeding with soft mashed vegetables and cereals was started at 6
months of age. Table food was given at 1 year of age. Not a picky-eater but prefers diet of fish.

Immunization Hx:
Claims complete immunization until one year of age given by the local health center. No booster at 5 y.o.
No noted adverse reaction to vaccines.

Menstrual Hx:
Menarche at 12 y.o. with regular interval lating for 5-7 days, consuming 2-3 napkins per day.

Neurodevelopmental Hx:

E
Shows no delays in terms of motor, cognitive, social and language development. Her developmental milestones

M
were at par with her age.

RO
Environmental Hx:
Px lives in a 1-story, well-ventilated, well-lit home with 7 other household members. They consume distilled water
for drinking. Grabage is collected 2x/week. No exposure to cigarette smoke and nearby factories or exposure to
chemicals.

D
Past Medical Hx:

YN
No previous surgeries, NKA

Physical Examination:
Awake, comfortable
AS
Anthropomentric measurements:
Weight: 28 kg, Length 135 cm, BMI:
VS:
M

HR = 102 bpm
BP = 90/50 mm Hg
IG

RR 25 cpm
T = 37.2 C (Axillary)
ST

Findings Remarks
EO

Skin (+) pallor

Eyes Anicteric sclerae

G

pale palpebral conjunctiva

Ears No ear discharge

Nose (+) alar flaring

No nasal discharge
Mouth & Throat Dry lips
Non-hyperemic
Non-enlarged tonsils
Neck (+) neck vein engorgement

Thorax & Lungs Equal chest expansion

(+) subcostal retractions
 (+) suprasternal retractions
(+) crackles at Right more than
left lung fields.
Cardiovascular Adynamic precordium
No heaves & thrills
Normal rate
Regular rhythm
Grade 3/6 holosystolic
murmur

Abdomen Flabby
Normoactive bowel sounds
No tenderness
Palpable liver edge
Genitalia Grossly female genitalia
Tanner stage V

E
Extremities Muscles with symmetrical bulk
and normal tone

M
No tenderness
Back Symmetrical shoulder

RO
Spine in midline
No curvature, deformities, pits,
dimples
D
YN

Neurologic Hx:
Mental status: Alert, Oriented, GCS 15
AS

Cranial Nerves
I Not tested
M

II Pupils 2-3 mm, reactive

IG

III, IV, VI Full EOMs

ST

V Good bite

VII No facial asymmetry

EO

VIII Can follow commands

IX, X Good gag
G

XI Turns head side to side

XII Tongue at midline

Sensory Sensitive to light touch
Motor 5/5 strength on all extremities,
good symmetry, no spasticity,
no flaccidity, no atrophy, no
hypertrophy
Reflexes No persistent primitive reflexes
(-) Babinski
DTRs No Clonus

Meningeal No nuchal rigidity

Management:

E
Px was admitted and was initially started on Cefuroxime then was shifted to Ceftriaxone, Furosemide, Enalapril and
Digoxin.

M
On the 4th hospital day, noted progression, minimal improvement of symptoms hence antibiotics was shifted to

RO
Piperacillin-Tazobactam. The patient was then started on spironolactone and aspirin.

On the 6th hospital day, noted hypotension, dopamine was started.

D
On the 8th hospital day, noted no recurrence of hypotension, dopamine was maintained.
YN
On the 15th hospital day, beginning to taper dopamine, antibiotics was shifting to Cefeprime.

On the 18th hospital day, noted hypotension hence dopamine was resumed, antibiotics shifted to Meropenem.
AS

On the 20th hospital day, the mother requested to transfer to another instituion but px expired during preparation
for transfer.
M

Laboratory results:
IG

On admission:
CBC:
Value Remarks
ST

Hgb 84
Hct 0.26
EO

RBC count 3.4

MCV 74.7
G

MCH 22.9

MCHC 30.7

WBC Count 9.87

WBC
Differential
Count
Neutrophil 0.54
Lymphocyte 0.34

Monocyte 0.11

Eosinophil 0.01
Basophil 0.00

Platelet count 390

E
M
Blood type: B+

RO
UA:
Color Light yellow
Transparency Clear

D
pH 6.0
YN
Spec. Gravity 1.015
Pus cells 0-2
RBCs 10-12
AS

Epithelial cells Rare

M
IG

4th HOD
CBC:
Value Remarks
ST

Hgb 112
Hct 0.33
EO

RBC count 4.29

MCV 77.4
G

MCH 24.2

MCHC 31.3

WBC Count 6.00

WBC
Differential
Count
Neutrophil 0.63
Lymphocyte 0.30

Monocyte 0.05

Eosinophil 0.01
Basophil 0.01

Platelet count 247

Chemistry:

Creatinine 0.41
Total Caclium 2.29

E
Ionized Calcium 0.99

M
Sodium 134.5

RO
Potassium 3.92
Chloride 99.8 D
YN

8th HOD

CBC:
AS

Value Remarks
M

Hgb 110
Hct 0.33
IG

RBC count 4.31

ST

MCV 76.1
MCH 24.4
EO

MCHC 32.0

WBC Count 12.2

G
WBC
Differential
Count
Neutrophil 0.72

E
Lymphocyte 0.30

M
Monocyte 0.05

RO
Eosinophil 0.01
Basophil 0.01

D
Platelet count 247

YN
AS
M
IG
ST
EO
G