PAUL RAJ, SHERINA SUNDARI 3rd YEAR
PEDIATRIC HISTORY AND PHYSICAL EXAMINATION
DATE: February 21, 2012 GENERAL DATA Patient: Maica Anillo, 15 yo, Filipino, Catholic Address: Cristobal, Manila Mother: Melosita Anillo Reliability: 95% - 98% Chief Complaint: Fever with cough and headache HIstory of Present Illness 1 day prior to consult, patient experienced on and off fever, 39degrees Celsius, with productive cough, spitting out white phlegm. She also complained of headache and pruritic maculopapular rashes on upper and lower extremities, which appeared with the onset of fever. Biogesic (500mg tab) given every 4 hours provided slight relief however, fever persisted. No complaints of vomiting or diarrhea Past Medical History No Major medical or surgical illnesses No previous hospital admissions. No known allergies. Immunization status - up to date HEADSS ASSESSMENT H- Home environmentSafe and protective home environment. Good parent-child interaction. E- EducationCurrently graduating 4th year student at V. Mapa High School A- ActivityActive student and fond of playing sports especially volleyball D- Diet/Drugs/DepressionWell balanced diet. No regular intake of medications or vitamins. Denies smoking, drinking and illicit drug use. S- SexualityHas a boyfriend. Denies sexual contact S- Suicidal ideationDenies suicidal ideation. Family History A. Illnesses - No family history of cardiac disease, hypertension, stroke, diabetes, cancer, abnormal bleeding, allergy or asthma. B. No family history of Mental retardation, congenital or chromosomal anomalies. Social History She lives in her family house with grandmother and 3 other siblings. Review of Systems
A. Weight - 46.5kgs. B. Skin and Lymph - Pruritic maculopapular rashes, no adenopathy, no lumps, no bruising and bleeding, no other pigmentation changes C. HEENT - headache(+), No concussions, No strabismus, No conjunctivitis, No visual problems, No hearing problems, No ear infections or draining ears, No cold and sore throats, No tonsillitis, No mouth breathing, No snoring or apnea No oral thrush, No epistaxis, No dental caries D. Cardiac - No cyanosis and dyspnea, No heart murmurs, Good exercise tolerance, No chest pain and palpitations E. Respiratory - No pneumonia, No bronchiolitis, No wheezing, cough(+), sputum(+), No hemoptysis F. GI - Normal stool color and character, No diarrhea, No constipation, No vomiting, No hematemesis, No jaundice, No abdominal pain, No colic, Normal appetite. G. GU - Normal frequency, No dysuria, No hematuria, No discharge, No abdominal pains, Normal urinary frequency, No previous infections, No facial edema H. Musculoskeletal - No joint pains or swelling, No scoliosis, No myalgia or weakness, No gait changes I. Pubertal - Normal secondary sexual characteristics, Normal menstrual cycle, dysmenorrhea(+) J. Allergy - No urticaria, No allergic rhinitis, No asthma, No eczema, No drug reactions History of menstrual period Menarche at 11 yo Last Menstrual period: Jan 19 Usually more than 30 days to almost 2 months before next period. Lasts an average of 4 days Uses an average of 2 pads/day Experiences dysmenorrhea but no meds taken for relief. PHYSICAL EXAMINATION Vital Signs BP. = HR. = 104 beats per minute RR. = 16 breaths per minute PR. = 96/minute Temp. = 37.9 degrees Celsius Skin: Dry flushed skin, smooth and warm to touch. Presence of Pruritic maculopapular rashes on upper and lower extremities. HEENT Eyes: Pink Palpebral conjunctiva. Tonsils not swollen. No palpable lymph nodes. ChestAuscultation: Posterior lung fields – clear breath sounds. Heart Abdomen GUT (-) kidney punch Neck Normal Thyroid and midline Trachea. No Masses, cysts, or nodes. Absence of nuchal rigidity.
Lungs/Thorax Inspection Normal respiratory pattern without strain. Normal chest retractions. Auscultation Clear and equal breath sounds. Absence of rales, wheezes, or rhochi Normal findings on Palpation and Percussion. Cardiovascular Auscultation Normal rhythm, no murmur. Normal Pulses Abdomen Normal, flat abdomen. Normal bowel sounds. Absence of rebound tenderness. Genito Urinary (-) kidney punch WORKING DIAGNOSIS To consider a viral illness due to the absence of specific focus. DIFFERENTIAL DIAGNOSIS • Urinary tract infection • Dengue MANAGEMENT Paracetamol given for fever Follow up after 3 days if fever still persists.