Patient: ULEP, JOHN MICHAEL Hospital No: 35950

Age/Sex:20/M Department: Medicine

Date of Admission: 11/4/18 Room No: 630
AMD: Dr. Raymond Dela Cruz

CLINICAL HISTORY
Chief Complaint: rashes

History of Present Illness:

Patient is s/p open appendectomy last October 29, 2018. Patient had unremarkable stay at the hospital and was eventually discharged on October 30,
2018.
Upon discharge, patient developed fever, intermittent, Tmax 38C, relieved by Paracetamol 500mg as needed. Patient was also noted with about 3-5
episodes of vomiting, of previously ingested meal, approximately ¼-1 cup per bout, No consult was done.
2 days prior to consult, fever and vomiting subsided. However, there was note of rashes on the trunk.
1 day prior to consult, patient still had rashes, now spreading to the extremities. Still, no consult done.
On the day of consult, rashes still persisted. Patient then came in for consult.

Past Medical History

s/p Appendectomy, MMC, Oct 29,2018
(-) HPN (-) DM (-) thyroid disease (-) PTB (-) BA (-) allergy

Family Hx
(-) HPN (-) DM (-) thyroid disease (-) BA (-) PTB (-) malignancies

Personal and Social History:

Non-smoker
Non- alcoholic beverage drinker

ROS:
General: (-) weight loss, (-) loss of appetite
HEENT: no sore throat, no dizziness, no gum bleeding, no epistaxis
CVS: no chest pain, no dyspnea
Genitourinary: no dysuria, no tea-colored urine
Gastrointestinal: no change in bowel movement
Endocrine: no polyuria, no polydipsia, no polyphagia

Physical Examination
General Survey conscious, coherent, weak-looking, not in distress
Vital Signs BP: 1380/80 HR: 89 RR: 23 O2 sat: 98% T: 37.1
Skin and integumentary Flushed skin, multiple maculopapular rashes on the face, trunk, extremities
HEENT anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, (+) palatal petechiae, no cervical
lymphadenopathies
Chest and Lungs symmetric chest expansion, clear breath sounds
Heart Adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen Soft, flat, non-tender, non-distended, normoactive bowel sounds
Extremities no cyanosis, no edema, full equal pulses, petechiae on both thighs

Present Working Impression

Dengue with Warning Signs

S/p Appendectomy (MMC, Oct 2018)

Drs. Foronda/ Salazar/ PGI Macasipot