GAVIOLA, THESSA TYRA G. Medicine 3 DMSFI General Data: Name: J. D.

Date of Birth: July 11, 1990 Age: 22 years old Sex: Male Status: Single Address: Malvar St., Davao City Religion: Roman Catholic Chief Complaint: Fever

October 18, 2013

Date Admitted: October 13, 2013 Date Interviewed: October 14, 2013 Informant: Patient Reliability: 95%

History of Present Illness: Four days prior to admission, the patient manifested with fever that was associated with body malaise, frontal headache, facial flushing, back pain, joint pain, altered taste sensation, and loss of appetite. He took Paracetamol 500mg 3x which provided temporary relief. Two days prior to admission, the signs and symptoms mentioned still persisted. However, this time, he took Phenylephrine HCl + Chlorphenamine maleate + Paracetamol (Bioflu) 1 tab 1x and this afforded no relief. One day prior to admission, the patient noted the appearance of rashes on his upper left chest which were described as petechial, flat, painless, not itchy with a size of 1 2mm as well as the disappearance of fever. Body malaise and joint pain were still persistent, and the onset of epigastric pain was noted. No medications were taken. Seven hours prior to admission, rashes were noted to spread to the arms, abdomen, thighs and legs with islands of skin sparing, with the epigastric pain still persistent. This prompted the patient to seek medical attention. Past Medical History: The patient had two previous hospitalizations: one in 1994, which he was diagnosed of diarrhea; and another in 2004, which was due to gastroenteritis. Patient has no known drug and food allergies. Immunizations received were BCG, HBV, OPV, MMR, and DPT. Family History/Personal History: His brother is a known asthmatic. No family history of asthma, hypertension, tuberculosis, diabetes mellitus, cancer, and congenital malformations. The patient is a non-smoker, non-alcoholic beverage drinker and non-drug abuser computer programmer. The patient lives in a boarding house with many nearby clogged canals and stagnant water.

REVIEW OF SYSTEMS: General: No alteration of consciousness, restlessness, recent weight changes Skin: No itching or dryness; no changes in hairs or nails Head, Eyes, Ears, Nose, Throat (HEENT): Head: No dizziness or lightheadedness Eyes: No orbital pain, visual disturbance or itchiness. Ears: No hearing difficulties, pain, or discharges. Nose, Mouth and Throat: No epistaxis, gum bleeding, sore throat, nasal discharges, dry mouth, or hoarseness. Neck: No pain or stiffness noted Respiratory: No cough, dyspnea Cardiovascular: No palpitation. No chest pain or discomfort. Gastrointestinal: No vomiting, hematemesis, rectal bleeding or tarry stools, dysphagia, changes in regular bowel movements, pain with defecation, hemorrhoids, constipation or diarrhea. Urinary: No hematuria, urinary frequency, and dysuria. Genital: No itching, sores. Musculoskeletal: No stiffness Neurologic: No changes in mood, attention, and judgment Hematologic: No easy bruising or bleeding. Endocrine: No heat or cold intolerance. No excessive sweating, excessive thirst or hunger Psychiatric: No depressive states or suicidal attempts.

PHYSICAL EXAMINATION: General: Patient was seen on the 2nd hospital day lying on bed, awake, coherent, not in respiratory distress, with IVF infusing well on his left metacarpal vein. Vital signs: BP: 120/80 mmHg HR: 78 bpm RR: 16cpm Temperature: 37.3 C Height: 56 (167.64 cm) Weight: 60 kg BMI: 21.3 kg/m2 Skin: Skin is fair in color, warm to touch with good skin turgor. Nails are convex. Capillary refill of less than 1 sec noted. Facial flushing is noted. The petechial, flat, painless, not itchy with a size of 1 2mm rashes were noted on the: Thorax (upper left thorax) Arm (medial side of the left arm) Abdomen (right upper quadrant) Thighs (both right and left medial thighs) Legs (anterior side of both legs extending to both ankles) With Islands of skin sparing

Head, Eyes, Ears, Nose, Throat (HEENT): Head: Normocephalic with no lesions and masses noted. Eyes: Symmetrical; conjunctiva is pink, sclerae are white. Pupils are round, equally reactive to light with a pupil size of 2-3 mm. Extraocular movements were observed. Ears: No mass, lesions and discharges. Nose: Septum in midline. No tenderness and discharges noted. Throat (or mouth and pharynx): Oral mucosa is pink without lesions. Tongue is in midline. Neck: Trachea is in midline. Neck veins were not distended. Lymph nodes were not palpable. Breasts: Symmetric, no palpable mass, nipples are everted. Chest: o Lungs Inspection: Symmetric, without deformities. No intercostal retractions. Palpation: No palpable mass or tenderness. Percussion: Both lung fields are resonant upon percussion. Auscultation: No adventitious sounds heard upon auscultation. o Cardiovascular Inspection: Precodium is adynamic Palpation: Apical pulse palpable in 5th intercostal space 12 cm from mid sternum. Auscultation: S1 and S2 distinct, normal Abdomen: Inspection: flat Auscultation: 15 bowel sounds per minute Percussion: dull right upper quadrant (liver span midsternum 4 to 8 cm, midclavicular 6 to 12 cm); the rest - tympanitic upon percussion Palpation: no tenderness and masses noted Extremities: No edema noted. Both the upper and lower extremities are symmetrical. No deformities, tenderness, or contractures. Peripheral Vascular: positive tourniquet test Neurologic: Mental status: the patient is oriented, aware with GCS score of 15 (4 eye opening; 5 verbal response; 6 motor response) Cranial Nerves: o I - able to smell o II able to see o III,IV,VI - Extraocular muscles are intact. Eyes can move medially, laterally, superiorly, and inferiorly. Direct and consensual pupillary reflexes are intact. o V - Facial sensation and corneal reflex are both intact and able to clench teeth and chew o VII - able to do facial movements, make face, blink, raise eyebrows and taste food o VIII - able to hear with both ears equally o IX, X gag reflex noted o XI - able to shrug shoulders and turn head side to side o XII - Tongue is in midline, not atrophic

 Cerebellar: o Rombergs test tested maintain balance of both raised arms when with eyes closed o Finger-to-nose test able to perform Motor system: Muscle strength all extremities are graded 5/5 Sensory system: Pain, temperature, light touch, vibration, and discrimination sense are intact Reflexes: o Deep tendon reflexes such as biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes and plantar reflexes are present, with a reflex grading of 2 o Babinski reflex absent ___________________________________________________________________________________ IMPRESSION: Dengue Fever

SALIENT FEATURES: Vital signs: o BP: 120/80 mmHg o HR: 78 bpm o RR: 16 cpm o Temperature: 37.3 C Living in an area with many clogged canals and stagnant water

PERTINENT POSITIVE Fever Petechial Rash Headache Back pain Facial flushing Altered taste sensation Loss of appetite Epigastric pain Body malaise Joint pain Positive tourniquet test

PERTINENT NEGATIVE No lymphadenopathy No itching No desquamation No respiratory symptoms No cough No coryza No conjunctivitis No photophobia No Kopliks spots No petechiae on mucous membrane

DIFFERENTIAL DIAGNOSES: RULE IN 1. Drug-induced Hypersensitivity Syndrome 2. Chikungunya

-Fever -Rash

RULE OUT
-No history of drug allergies -Rashes are not symmetric -No scaly lips -Positive tourniquet test -No severe joint pain -No hepatomegaly -Positive tourniquet test

-Fever -Rash -Malaise -Headache -Joint pain Fever -Rash -Malaise -Anorexia -Joint pain

3. Meningococcemia

4. Measles (Rubeola)

Fever -Rash -Malaise -Abdominal pain -Loss of appetite -Headache

5. German measles (Rubella)

-Fever -Rash -Malaise

-Petechial rash (not purpuric) -No petechiae on mucous membrane -No tachypnea & tachycardia -No cough -No sore throat -No nausea and vomiting -Positive tourniquet test -Rashes did not begin behind the ears, along the hairline -Did not spread centrifugally -No cough, coryza -No conjunctivitis -No photophobia -No Kopliks spots -Positive tourniquet test -No lymphadenopathy -Rash did not begin on the face and spread rapidly on the first day -No itching -No desquamation -No respiratory symptoms -High grade fever -Positive tourniquet test

6. Dengue

-Fever and headache -Petechial Rash -Back and joint pain -Facial flushing -Altered taste sensation -Loss of appetite -Epigastric pain -Body malaise -Positive tourniquet test -Lives in an environment with many clogged canals