Clinical HistoryA. General Data

a. Name: b. Age:c. Birth Date:d. Sex:e. Birthplace:f. Religion:g. Present Address:h. Number and Date of Hospital Admissionsi. Name of Informant and Relation to Patient:j. Reliability

B. Chief ComplaintC. History of Present Illness

a. 6 days PTAi. Patient complained of frontal headache and retrorbital pain with

a pain rate of 5/10. No accompanying rash, fever, cough, colds, chills, coryza, and joint pains. Headache was relieved by Biogesic 500 mg taken once a day. No consult was done.

b. 5 days PTAi. Headache persisted but with accompanying fever with

unrecorded temperature and body malaise. The patient continued taking Biogesic but still no consult was done.

c.

d. 3 days PTAi. The above symptoms of the patient persisted accompanied by

anorexia. Biogesic

e. 1 day PTAi. The patient

Additional Questions- chills,- bed rest- hydrate

abdominal paindiarrhea

D. Review of Symptoms

E. Personal Historya. Development and Behavioral Historyb. HEADS/S/FIRST

HomeEducationAbuseDrugsSafetySafetySexuality/Sexual IdentityFamily and FriendsImageRecreationSpirituality & ConnectednessThreats & Violence

c. Menstrual History MenarcheDurationFrequencyProblems in Menstruation

d. Self Breast ExaminationF. Past Illnesses

Contagious Diseases: Past admissionsSurgeriesAllergyAsthmaInjuries

G. Immunization HistoryH. Family History

a. Parents AgeOccupationState of healthIf not living, age and cause of death

b. SiblingsNumber

AgesState of health

c. Familial Illness or AnomaliesTBDMCancerEpilepsyRheumatic feverAllergy

I. Socioeconomic HistoryPlace and nature circumstances of dwellingNumber of persons living in the houseSources of funds

J. Environmental HistoryExposure to cigarette smokeGarbage disposalSewage disposalWater sourceFlooding

Physical Examinationa. General Survey

Mental state, sensorium, level of activityAmbulatory bed riddenState of hydration

b. Vital SignsTempBPPRRR

c. Anthropometric DataHeightWeight

d. SkinColorTurgorRashHemorragesScarEdemajaundice

e. HeadHair quantityColor

TextureLice and nitsStrength

f. FaceAsymmetryExpressionsDeformitieslumps

g. EyesLidsConjunctivaSclera – size, rxn to lightPupilsEom - HVision – snellenROR – dx setCorneal light reflex – penlight

h. EarsSizeShapeLocationPositionDischargeTM – dx set

ContinuityIntact or perforatedColorCone of lightBulging/concave

i. Nose and Paranasal SinusesPatency of naresDischargePosition of septumSinus tenderness

j. Mouth and ThroatLips – color,moisture, drynessThroat – tongue dep penlightGums – color, lesions, bleedingTongue – midline, color, moisture, abnormal movementsOropharyngeal mucosa – thrush, vesicles, ulcers, Koplik spots

k. NeckFlexibility

MassesLymph nodesSwellingThyroidTrachea

l. Chest and Lungsm. Heart n. Abdomeno. Inguinal Regionp. Genitaliaq. Extremities

Neurological Examination

Salient Features

HPIPhysical Exam

Approach to Diagnosis

Differential Diagnoses

Working Diagnosis

Diagnostic Laboratory Exams Virus isolation – Virus can be recovered from acute phase serum after

inoculating tissue culture or living mosquitoes. NS1 Antigen – a reliable point of care diagnosis of acute dengue infection where

a viral nonstructural protein, NS1, is released by infected cells into the circulation and can be detected using monoclonal or polyclonal antibodies.

PCR – Detects viral RNA in blood or tissues by specific complementary RNA probes

Serologic Tests – Following primary and secondary dengue infections, there is relatively transient appearance of anti-dengue immunoglobulin (IgM) antibodies. These disappear after 6-12 weeks, a feature that can be used to time a dengue infection. In second primary infections, most antibody is of the IgG class.

Torniquet Test Complete Blood Count – pancytopenia may occur after 3-4 fays of illness.

Neutropenia may persist or reappear during the latter stage of the disease and may continue with convalescence. Monitor hematocrit and platelet count for

possible hematologic abnormalities and progression to dengue hemorrhagic fever or dengue shock syndrome.

TreatmentUncomplicated dengue fever is supportive. Bed rest is advised during the febrile

period. Antipyretics should be used to keep body temperature <40’ C. Analgesics or mild sedation may be required to control for pain. Aspirin is contraindicated and should not be used because of its effects on hemostasis. Fluid and electrolyte replacement is required for deficits.

Vital signs, degrees of hemoconcentration, dehydration, and electrolyte imbalance must be monitored. Transfusions of fresh blood or platelets should not be given during hemoconcentration, but only after evaluation of hemoglobin and hematocrit values