Theopistanni Faith P. Bartolome PDR-2 General Data: A case of S.

U, a twelve-year old male, born on October 28, 2006 in Cagayan de Oro City, Roman Catholic, and currently residing in Lapas Uno, Lapasan, Cagayan de Oro City. Patients informant, his mother, was interviewed with 80 % reliability last November 16, 2008 at 2:30 P.M at the German Doctors Medical Hospital, Cagayan de Oro City. Chief Complaint: Generalized body weakness History of Present Illness: According to the mother, eleven days prior to consultation on November 14, 2008, patient went home from school with high fever, chills and headache. His appetite was poor and he only ate green bananas. He also kept on lying on bed. He took 1 tablet of 500 mg Paracetamol every 4 hours for 1 day as instructed by his mother. Three days after, headache and chills were relieved. On the morning of November 10, 2008, patient complained of loose bowel movement. Mother described stool as wet, brownish to greenish in color, fishy in odor, and about 1 to 3 glasses in amount. Patient also experienced abdominal pain or butod as his mother described it and intermittent fever. Appetite was still poor and was only fed with rice porridge and banana. Patient still kept lying on bed. His mother gave him 1 teaspoon of Metronidazole, 3 times a day from November 10 to November 11, 2008. He was also given twice 1 capsule of 500 mg Loperamide on November 12, 2008. Loose bowel movement was relieved on November 13, 2008. On November 14, 2008, patient fell down on his way to the bathroom. He still had intermittent fever and poor appetite and he had generalized body weakness. These prompted the patients father to bring him to the hospital. At noon, patient was admitted at the German Doctors Medical Hospital. Interval History On the first day of hospitalization, the mother said that patient felt better and was able to walk on his own to the comfort room although still with high grade intermittent fever and poor appetite. Patient did not defecate that day. No significant changes happened on the second day of hospitalization last November 15, 2008. However, appetite improved. On the third day of hospitalization, patient still had intermittent fever, body temperature was 38.9 degree Celsius and he defecated once. Stool was brown, semi-formed and about 1 glass in amount. At 1:00 P.M. gnawing, epigastric abdominal pain with an estimated severity of 6/10 recurred acutely for 5 minutes. Condition was relieved by the application of Efficacent oil on the abdomen. Precipitating factors were not recognized. On November 17, 2008, the fourth day of hospitalization, fever still did not subside. Body temperature was 38.7 degree Celcius. However, abdominal pain was already relieved and appetite was already fair. Patient was also able to walk on his own way to the comfort room.

Review of Systems: Patient was assessed on November 17, 2008. General: No weight loss and appetite was fair. Patient kept lying on bed. Cutaneous: No rashes, pigmentation, acne, pruritus, hair loss observed. Head: Patient complained of dizziness without headache. No visual and hearing difficulties. No oral and nasal discharges. No epistaxis, toothache, or sorethroat. Neck: No lumps, goiter, swollen glands, and pain. Cardiovascular: There was easy fatigability. No orthopnea and cyanosis. Respiratory: No cough or difficulty of breathing. Gastrointestinal: No vomiting, jaundice and food intolerance. Genetourinary: Urine was light yellow and no burning sensation upon urination. No abnormal discharges. No edema of the hands and feet. Endocrine: No cold or heat intolerance. No polyuria and polydypsia. No difficulty in sleeping at night. Nervous/Behavioral: No behavioral problems, memory loss, and paralysis. Musculoskeletal: No bone, joint and muscle pains. No swelling. Hematopoietic: Patient had pallor. No bleeding manifestations. Peripheral Vascular: Peripheral pulses were palpable. Capillary refilling time was 2 seconds each for the hands and feet. Past Personal History