What is the diagnosis and recommended treatment for a 13-year-old male patient presenting with cough, yellow phlegm, fever of 39.7°C, and 4 episodes of watery stool?

Medical Assessment and Treatment Plan

Diagnosis

This 13-year-old male patient has Acute Gastroenteritis with Upper Respiratory Tract Infection (Acute Viral Syndrome). The combination of watery diarrhea (4 episodes), productive cough with yellow phlegm, and high fever (39.7°C) represents a common viral illness with both gastrointestinal and respiratory involvement 1, 2.

Clinical Reasoning

Key Diagnostic Features

• Fever of 39.7°C with watery stools: This presentation is consistent with acute viral gastroenteritis, where fever is self-reported in up to 30% of patients with traveler's diarrhea and similar acute diarrheal illnesses 1
• Productive cough with yellow phlegm: While yellow sputum might suggest bacterial infection, acute bronchitis in this age group is predominantly viral and does not require antibiotics unless pertussis is suspected 3
• No signs of severe respiratory distress: The absence of respiratory distress, high respiratory rate, or oxygen desaturation indicates this is an upper respiratory tract infection rather than pneumonia 1, 2

Why Antibiotics Are NOT Indicated

• Acute bronchitis is typically viral and antibiotics are not indicated in patients without chronic lung disease 3
• The presence of fever does NOT automatically indicate bacterial infection requiring antibiotics 1, 2
• Routine antibiotic use in upper respiratory infections enhances unnecessary future consultations and antibiotic resistance 4

Treatment Plan (PhilHealth Konsulta-Compliant)

Medications to Dispense

1. Paracetamol 500mg tablets

• Dosing: 500mg every 6 hours as needed for fever
• Dispense: 20 tablets (5-day supply)
• Purpose: Antipyretic and analgesic 1

2. Oral Rehydration Solution (ORS) sachets

• Dosing: 1 sachet dissolved in 1 liter of water, drink frequently throughout the day
• Dispense: 10 sachets (5-day supply)
• Purpose: Prevent dehydration from diarrhea 1, 5

3. Cetirizine 10mg tablets

• Dosing: 10mg once daily
• Dispense: 5 tablets (5-day supply)
• Purpose: Symptomatic relief of cough and rhinorrhea 2

Estimated Total Cost: Approximately 150-200 pesos (well within 300 peso limit)

Non-Pharmacologic Management

• Rest: Adequate sleep and activity restriction for 5-7 days 5, 6
• Hydration: Increase fluid intake beyond ORS, including water and clear soups 5
• Diet: Continue regular diet as tolerated; avoid fatty or spicy foods during diarrhea 1

Red Flags Requiring Immediate Return

Return immediately if any of these develop:

• Breathing difficulties or respiratory distress 1
• Persistent vomiting >24 hours preventing oral intake 1
• Signs of dehydration (decreased urination, extreme thirst, dizziness) 1
• Fever persisting beyond 72 hours despite paracetamol 5
• Bloody stools or severe abdominal pain 1
• Altered consciousness or extreme drowsiness 1, 6

Follow-Up Recommendations

• Reassess in 5-7 days if symptoms do not improve 5
• Expected improvement: Fever should resolve within 48-72 hours, diarrhea within 3-5 days, cough may persist up to 2 weeks 2, 3

Medical Certificate

This certifies that the patient has been seen and examined today with the diagnosis of:

Acute Gastroenteritis with Upper Respiratory Tract Infection (Acute Viral Syndrome)

Recommendation:

Rest and home care for 5-7 days with symptomatic treatment. Patient is advised to stay home from school during this period to prevent transmission to others and allow adequate recovery. Patient may return to school after 24 hours of being fever-free without antipyretics and when diarrhea has resolved. NOT FIT FOR SCHOOL during treatment period.

This medical certificate is issued upon the request of the patient for school absence/excuse from classes.

Patient/Parent Education

Explanation of Medical Condition:

Ang inyong anak ay may viral infection na nakakaapekto sa tiyan (gastroenteritis) at respiratory tract. Ito ay karaniwan at self-limiting, ibig sabihin ay gagaling ito sa loob ng 5-7 araw kahit walang antibiotics. Ang high fever, ubo na may plema, at watery stool ay normal na symptoms ng viral infection. Ang pinakamahalagang treatment ay pahinga, maraming tubig, at paracetamol para sa lagnat. Hindi kailangan ng antibiotics dahil viral ang sakit, at ang antibiotics ay hindi gumagana sa virus 2, 4, 3.

Siguraduhing uminom ng ORS para maiwasan ang dehydration mula sa diarrhea. Kung lalala ang symptoms o may mga red flags na nabanggit, bumalik kaagad sa clinic 1, 5.