General Data

This is a case of JDB, a 12 year old adolescent, Male, a Roman Catholic, resides at Sta. Cruz,
Lumbia, Cagayan de Oro City. This was his first admission. The source of information was
the patient himself and his mother both with 90% reliability.

Date of Birth: March 24, 2007

Date and Time of Admission: September 30, 2019
Date and time of Interview: October1, 2019 at 8:00 AM
Hospital of Admission: Northern Mindanao Medical Center

Chief Complaint
Body Malaise and Vomiting

History of Present Illness

4 days PTA, there is onset of undocumented fever. No other signs and symptoms noted.
3 days PTA fever still persisted and now accompanied with aching epigastric pain, 7/10 on
the pain scale and 3 episodes of postprandial vomiting with unrecalled amount of vomitus.
Patient was given Paracetamol (Biogesic) 500 mg tablet at 7:00 PM.
2 days PTA, fever and abdominal pain still persisted with 1 episode of vomiting and
anorexia. Another tablet of Paracetamol 500mg was given to patient. A day PTA abdominal
pain and fever still persisted, no vomiting noted. Patient’s mother took him to a
manghihilot. No consultation done.
Morning PTA patient and mother sought consultation at the City Hospital for the on-and-off
fever and abdominal pain. While queuing, patient vomited. Patient’s mother then
transferred to NMMC for the consultation but patient was already complaining of body
weakness and dyspnea which prompted immediate admission.

Past Medical History

Gestational History
JDB’s Mother, MB was 24 years old when she was pregnant with JDB. Her current OB score
is G5P5. She claimed she was in good health and maintained proper nutrition during the
duration of the pregnancy. She also claimed that there were no episodes of vaginal
bleeding, trauma, hypertension, fever, but did note a vaginal yeast infection at some point
during her pregnancy. In addition, she had not taken any illicit drugs, smoked cigarettes,
drank alcohol or exposed to radiation.

Birth History
JDB was born at term (AOG unrecalled) via normal spontaneous vaginal delivery. Baby was
delivered at home and a ‘mananabang’ assisted during the delivery. Delivery was
uncomplicated.

Neonatal History
JDB’s weight upon delivery was unrecalled but was noted to be pink with vigorous cry,
active muscle tone, and had a prompt response to stimulation. APGAR score is unknown
but mother remembered baby breathing spontaneously at birth. No breathing problems,
birth injuries and jaundice were reported. No resuscitation was required.

Feeding History
JDB was exclusively breastfed for one year during infancy. Formula was given to him from
2 years old to 5 years old. Solid foods were introduced to him when he was 6 months old.
JDB is not a picky eater and has a healthy appetite according to his mother.

Developmental and Behavioral History

JDB is currently in the sixth grade at Lumbia Elementary School. JDB gets along with his
parents and he liked his school and teachers. He has 12 close friends and he likes to play
basketball and mobile games. He claims he hasn't used drugs or alcohol and has no issues
regarding his sexuality or sexual orientation. He has no depressive episodes or suicidal
tendencies. He does not carry weapons around to protect himself. ​For the social media
usage, JDB goes to a computer shop twice per week to access Youtube, Facebook and play
Rules of Survival (ROS). He spends an average of 3 hours using social media. He was never
cyberbullied, experienced sexting or encountered an online user asking to have sexual
relationship with him ​(Rephrase)`

Developmental Milestones
JDB first smiled at 2 months; roll over at less than a month; sit alone at 2 months; crawl at 4
months; started walking at 1 year old; was able to run at 1 year and 2 months; said his first
word at 1 year and 1 month; and was toilet-trained at 2 years old.

Past Medical History

JDB has no history of major medical illnesses. He was circumcisised at the age of 10 with
nno complications. He also has no previous hospital admissions. He has no known allergies
to medications.

Immunization History
JDB completed his vaccines except for the MMR. He was able to receive the first dose at 1
month old but wasn't able to go back to the health center for the second shot at 9 months
old.

Family History
Genogram

— genogram —

JDB’s maternal grandmother and paternal grandfather both have hypertension. Paternal
grandmother died due to childbirth complications. The patient’s mother, MB is 36 years old
and works as a barangay police officer while his father is 48 years old and works as a
contractual construction worker.

Socioeconomic History and Environmental History

Patient lived together with his parents and 4 other siblings. Both of his parents were
working to support their family. Their area did not have a water supply and has to buy
water by gallons at the nearby town. JDB’s father smokes cigarettes anywhere in their
house. The family burns their garbage. The family also raises livestock which includes a pig,
a goat, chickens and a pet dog and cat. Another case of dengue affecting a 5 years old was
also noted in the nearby town.

B. Review of Systems
A. General: Unusual weight gain or loss, fatigue, temperature sensitivity, mentality. Pattern
of growth
(record previous heights and weights on appropriate graphs). Time and pattern of
pubescence.
B. Eyes: Have the child's eyes ever been crossed? Any foreign body or infection, glasses for
any reason.
C. Ears, Nose and Throat: Frequent colds, sore throat, sneezing, stuffy nose, discharge,
post-nasal drip,
mouth breathing, snoring, otitis, hearing, adenitis.
D. Teeth: Age of eruption of deciduous and permanent; number at one year; comparison
with siblings.
E. Cardiorespiratory: Frequency and nature of disturbances. Dyspnea, chest pain, cough,
sputum, wheeze,
expectoration, cyanosis, edema, syncope, tachycardia.
F. Gastrointestinal: Vomiting, diarrhea, constipation, type of stools, abdominal pain or
discomfort,
jaundice.
G. Genitourinary: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of
stream, vaginal
discharge, menstrual history, bladder control, abnormalities of penis or testes. Details of
menarche and
menstruation for adolescent females
H. Neuromuscular: Headache, nervousness, dizziness, tingling, convulsions, habit spasms,
ataxia, muscle
or joint pains, postural deformities, exercise tolerance, gait.

C. Physical Examination