What is the diagnosis and treatment for a child with fever, body pain, cough, and vomiting, given the lab results?

Medical Assessment para sa 5-Taong Gulang na Lalaki na May Lagnat, Pagsusuka, at Ubo

Ang batang ito ay may viral upper respiratory tract infection (URTI) na may gastrointestinal symptoms, at hindi nangangailangan ng antibiotics. 1

Diagnosis

Acute Viral Upper Respiratory Tract Infection with Gastrointestinal Symptoms

Ang clinical presentation ng lagnat ng 2 araw, pagsusuka, pananakit ng katawan, at konting ubo ay consistent sa viral respiratory infection. 1 Ang CBC results na nagpapakita ng neutrophilia (80%) at relative lymphopenia (17%) ay maaaring makita sa early viral infections, ngunit hindi ito specific para sa bacterial infection na nangangailangan ng antibiotics. 2

Mahalagang tandaan: Ang viral URTIs ay hindi nangangailangan ng antibiotics, laboratory testing, o imaging studies. 1, 3 Ang paggamit ng antibiotics para sa viral infections ay isang critical error na nag-aambag sa antimicrobial resistance nang walang benefit. 1

Requested Tests/Recommendation

• Walang karagdagang tests na kailangan - Ang CBC at UA ay natapos na at walang findings na nagpapakita ng bacterial infection
• Supportive care at home monitoring 1
• Return for reassessment kung: 1
  • Tumaas ang hirap sa paghinga o may respiratory distress
  • Hindi makakain o uminom (signs of dehydration)
  • Lumalala ang symptoms o hindi gumagaling after 48 hours
  • May bagong concerning symptoms

Plan/Recommendation

Symptomatic Treatment (PhilHealth Konsulta Formulary-compliant):

1. Paracetamol 250mg tablet

   • Dose: 1 tablet every 6 hours as needed for fever >38°C or body pain
   • Dispense: 20 tablets
   • Duration: 5 days
   • Estimated cost: ₱20-40

2. Lagundi (Vitex negundo) 300mg tablet

   • Dose: 1 tablet 3 times daily for cough
   • Dispense: 15 tablets
   • Duration: 5 days
   • Estimated cost: ₱30-50

3. Oral Rehydration Solution (ORS) sachets

   • Give frequently for vomiting and to prevent dehydration
   • Dispense: 10 sachets
   • Estimated cost: ₱50-100

Total estimated cost: ₱100-190 (well within ₱300 budget)

General Care Instructions: 1

• Hydration: Magpainumin ng maraming fluids para maiwasan ang dehydration 1
• Rest: Magpahinga ang bata 2
• Fever management: Paracetamol para sa lagnat at pananakit ng katawan 2, 1
• Iwasan ang exposure sa usok 2

Red Flags - Bumalik agad kung: 1

• May hirap sa paghinga o mabilis na paghinga
• Hindi makakain o uminom, signs ng dehydration (dry lips, walang luha, bihirang umihi)
• Patuloy na pagsusuka at hindi makainom
• Lumalala ang lagnat after 48 hours ng treatment
• Lumilitaw ang bagong symptoms tulad ng chest pain o bloody sputum

Explanation ng Medical Condition

Ang inyong anak ay may viral infection sa respiratory tract (daanan ng hininga) na karaniwang nangyayari sa mga bata. 1 Ito ay sanhi ng virus, hindi bacteria, kaya hindi kailangan ng antibiotics. 1, 3

Ang pagsusuka ay maaaring bahagi ng viral infection o dahil sa lagnat. 2 Ang CBC results ay normal para sa viral infection at hindi nagpapakita ng bacterial pneumonia. 2

Karamihan ng mga batang may viral respiratory infections ay gagaling sa loob ng 5-7 days gamit lamang ang supportive care. 1 Ang pinakamahalagang treatment ay ang pagpapahinga, pag-inom ng maraming fluids, at pag-manage ng lagnat. 2, 1

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Medical Certificate

This certifies that patient has been seen and examined today with the diagnosis of: Acute Viral Upper Respiratory Tract Infection with Gastrointestinal Symptoms

and recommendation of: Home management with supportive care (adequate hydration, antipyretics for fever, rest). Return for reassessment if symptoms worsen or fail to improve within 48 hours, or if signs of respiratory distress or dehydration develop.

This medical certificate is issued upon the request of the patient for whatever purpose it may serve.