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History and Physical ExaminationIris B. Lim, MDPGI- Department of PediatricsGeneral DataF.G.V15-year-old-MaleSingleRoman CatholicSeptember 20, 1999Currently residing at AFPOVAI Taguig CityAdmitted on August 20, 2015

INFORMANT: Father

RELIABILTY: 90%

Chief ComplaintFeverHistory of Present IllnessTwo days PTA:Undocumented fever HeadacheBody malaiseDecrease in appetiteNo other associated symptomsSelf medicated: Ibuprofen (Advil)Phenylephrine HCl/Chlorphenamine maleate/Paracetamol (Bioflu)No consult doneHistory of Present IllnessOne day PTA: Undocumented feverHeadacheBody malaiseDecrease in appetite3 episodes of vomiting (previously ingested food)Continued to self medicate, no consult done

History of Present IllnessFew hours PTA:

Still with above symptoms except vomitingConsult: 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: 295,000Findings: UTI (wbc/pus cells: 15-20)Unrecalled medication was givenTransferred at our institution

History of Present IllnessAt 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 SystemImmunizationGrowth and DevelopmentPast Medical HistoryFamily HistoryPersonal & Social HistoryUNREMARKABLEPhysical ExaminationGeneral Survey:Conscious, coherent, ambulatory, not in cardiorespiratory distress, febrile

Vital Signs:BP: 100/60mmHg CR: 128 bpmRR: 28cpm Temp: 39.50CWt: 67.8kg

Physical ExaminationSkin: 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, (-)CLADPhysical ExaminationChest/Lungs: Symmetrical chest expansion, no retractions, clear breath soundsCardiovascular: Adynamic precordium, tachycardic, regular rhythm, no murmurAbdomen: Flabby, normoactive bowel sounds, soft, non-tenderExtremities: Grossly normal with full and equal pulses,(-) edemaNeurologic ExaminationEssentially normalImmunization HistoryComplete as claimedPast Medical History(-) Asthma (-) PTB(-) Hypertension (-)Diabetes Mellitus(-) Allergies: food or medications(-) Hospitalization

Family History (-) Asthma (-) PTB(-) Hypertension (-)Diabetes Mellitus(-) CVD(-) Blood dyscrasia/bleeding tendenciesPersonal and Social History(-)Smoker(-)Alcoholic beverage drinker Admitting DiagnosisDENGUE FEVER T/C URINARY TRACT INFECTION