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Villanueva HX AND PE

This document summarizes the history and physical examination of a 15-year-old male patient admitted to the hospital with fever, headache, body aches, and decreased appetite for 2 days. Upon examination at admission, the patient was febrile with flushed skin and a petechial rash. Laboratory tests showed thrombocytopenia and pyuria. The admitting diagnoses were dengue fever and urinary tract infection.

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iris lim
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25 views14 pages

Villanueva HX AND PE

This document summarizes the history and physical examination of a 15-year-old male patient admitted to the hospital with fever, headache, body aches, and decreased appetite for 2 days. Upon examination at admission, the patient was febrile with flushed skin and a petechial rash. Laboratory tests showed thrombocytopenia and pyuria. The admitting diagnoses were dengue fever and urinary tract infection.

Uploaded by

iris lim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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History and Physical

Examination
Iris B. Lim, MD
PGI- Department of Pediatrics

General Data
F.G.V
15-year-old-Male
Single
Roman Catholic
September 20, 1999
Currently residing at AFPOVAI Taguig City
Admitted on August 20, 2015

INFORMANT: Father

RELIABILTY: 90%

Chief Complaint
Fever

History of Present Illness


Two days PTA:
Undocumented fever
Headache
Body malaise
Decrease in appetite
No other associated symptoms
Self medicated: Ibuprofen (Advil)
Phenylephrine HCl/Chlorphenamine
maleate/Paracetamol (Bioflu)
No consult done

History of Present Illness


One day PTA:
Undocumented fever
Headache
Body malaise
Decrease in appetite
3 episodes of vomiting (previously ingested
food)
Continued to self medicate, no consult done

History of Present Illness


Few hours PTA:
Still with above symptoms except vomiting
Consult: GM clinic/lying in (CBC with platelet count
& urinalysis were done) hgb: 160, hct::0.48, wbc:
6.8, seg: 0.63, lymphocytes: .37, PC: 295,000
Findings: UTI (wbc/pus cells: 15-20)
Unrecalled medication was given
Transferred at our institution

History of Present Illness


At the Emergency Room:
- Laboratory examination : CBC with Platelet
count and urinalysis
- revealed thrombocytopenia (Hgb: 155, hct:
0.48, wbc: 3.0, seg: .67, lympho: .33, PC: 96,000)
and pyuria (pus cells:16-18)
- Hence admitted

Review of System

E
L
B
A
K
R
A

Immunization
Growth and Development
Past Medical History
Family History
Personal & Social History

M
E
R
N
U

Physical Examination
General Survey:
Conscious, coherent, ambulatory, not in
cardiorespiratory distress, febrile

Vital Signs:
BP: 100/60mmHg
RR: 28cpm
Wt: 67.8kg

CR: 128 bpm


Temp: 39.50C

Physical Examination
Skin: Flushed, warm to touch, good skin turgor,
(+) petechial rash (torniquet test) right upper
extremity

HEENT: Anicteric sclerae, hyperemic palpebral


conjunctivae, no nasoaural discharge, (+)
tonsillopharyngeal congestion, (-)CLAD

Physical Examination
Chest/Lungs: Symmetrical chest expansion, no
retractions, clear breath sounds

Cardiovascular: Adynamic precordium,


tachycardic, regular rhythm, no murmur

Abdomen: Flabby, normoactive bowel sounds,


soft, non-tender

Extremities: Grossly normal with full and equal


pulses,(-) edema

Neurologic Examination
Essentially normal

Admitting Diagnosis
DENGUE FEVER
T/C URINARY TRACT INFECTION

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