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PRIMARY CARE
ROTATION 4
ID : 012013100122
SUPERVISOR : DR HAN
GENDER FEMALE
RELIGION ISLAM
ETHNICITY MALAY
CHIEF COMPLAINT
Mrs. Norelinah, a 44 year old woman from Klang come with chief complaint of fever and vomiting for 4
days
HISTORY OF PRESENT ILLNESS
Mrs. Norelinah with no underlying disease was apparently well untils he suddenly developed fever for 4
days. The fever was high grade fever, sudden in onset associated with chills and rigor, and intermittent in
nature. She took paracetamol that she bought in the pharmacy however it only temporarily relieved the
fever. Temperature was not recorded at home. The fever was associated with with vomiting and
generalized muscle and joint pain and reduced oral intake and reduced urine output.
Other than that, patient had vomited for 2 episodes per day for 4 days. The vomitus was small in amount
about 3 table spoon and she frequently vomiting after meal. So the vomitus contain mainly food particle
and It was a non-projectile and yellowish in colour. The vomitus contain no blood or mucus. She did not
take any medication at home for this symptom.
Besides that, patient did mentioned she had reduced oral intake for the last few days and also having
generalized body aches. She only managed to drink about one 1.5 litre bottle in a day. However, there is
no significant loss of weight noted. She also had reduced urine output which she normally urinates more
than 6 times a days but currently right now only 2 to 3 times a day.
She denied of having dengue warning signs such as abdominal pain, persistent vomiting, persistent
diarrhea, lethargy or bleeding tendency for example no gum bleeding or epistaxis.
The neighbourhood that she currently live in is a dengue prone area and fogging was done twice a week.
Th recent fogging was done a week ago from the day of clerking.
Otherwise, patient does not a history of jungle trekking, swimming in the waterfall or river or travelling
to malaria prone area . There is also no history of eating outside food and those who have similar illness
like her.
This is her 2nd time coming to Klinik Kesihatan Botanik, previous on her first visit yesterday, she was
asked to do a blood test and Combo test. Her platelet count is low and the Combo test showed that NS1
antigen was positive. She was asked by the doctor to drink more water, get enough rest and come again
the next following day.
Today, the day of clerking, blood test was done again and her platelet count is slightly increasing from
yesterday
FAMILY HISTORY
Mr. Noreliniah is happily married and has 2 children. She has 4 siblings and both of his parents are still
alive. Her father is a known case of hypertension on medications.. Her children are all healthy. Otherwise,
beside her father, all her family member does not have chronic illness or malignancies.
SOCIAL HISTORY
Mrs. Noreliniah live in Taman Sri Andalas. She and her husband both are teachers. She and her
husband did not smokes and consumes alcohol. Her housing area is a dengue prone area
SYSTEMIC REVIEW
GENERAL No fatigue/lethargy/malaise
No loss of appetite
Weight :
Height :
BMI :
GENERAL INSPECTION AND EXAMINATION
PARTS FINDINGS
Hands Warm and pink hands
No tobacco stainning of nails
No cyanosis present
No pallor of palms
Capillary refile time is less than 2 seconds
ABDOMINAL EXAMINATION
Inspection:
Abdomen was flat and not distended. The flank was not full.
Umbilicus was centrally located and inverted
All nine quadrants moves symmetrically with respiration.
There is no visible mass, dilated vein and surgical scars can be seen.
Palpation:
Percussion
Auscultation
Inspection :
Palpation :
Percussion :
Auscultation :
CARDIOVASCULAR SYSTEM
Inspection :
Palpation :
Auscultation :
DIFFERENTIAL DIAGNOSIS
haemoglobin
haemoglobin
Interpretation :
White blood cell result on 20th April is low and it is getting increasing based on the latest
result which is on 21st April
The platelet is increasing from 111 x 103 / L to 168 x 103 / L .The target platelet for
this patient is 200 x 103 / L
Hematocrit is stable
Rapid Combo Test
Dengue NS1 antigen: Positive
Antibody IgG: Negative
Antibody IgM Negative
Interpretation :
NS1 is useful for early dengue marker. NS1 positive indicate it is a acute dengue infection
IgM is negative. So, a repeat sample must be taken in recovery phase
MANAGEMENT
Non pharmacological:
Pharmacological:
In addition:
In this patient, first of all we need to have a several ideas and diagnosis regarding fever. Fever itself is a
huge topic and a proper approach and examination should be done. This patient Mrs. Norelinah had a 4
days fever and diarrhea.
She is high likely to have a dengue infection by evidence of positive NS1 antigen in Rapid Combo Test
and Low platelet count in blood test. What we worry the most regarding dengue are plasma leakage,
bleeding and organ impairment. In these case, a proper monitoring and management should be carried
out.
Just recently last 3 weeks ago on 7th April 2017, the Health Ministry has approved the dengue vaccine to
be used in Malaysia. This is a great news for Malaysia as dengue fever has a potential to be a life
threatening illness.
The vaccine gives an overall average of 66% protection against dengue infection, 93% against severe
dengue and 80% against hospitalisation for dengue, for those aged between nine and 16.
Dengue fever is a vector-borne disease caused by infection of Dengue virus transmitted by female
mosquito Aedes aegypti and Aedes albopictus
Classification:
2. Severe dengue (severe shock +/-: respiratory distress, severe hemorrhage and organ failure)
Based on examination, Mrs.Norelinah does not show any abnormal finding that can suggest that she in a
severe condition. Mrs. Norelinah seems improving based on increasing platelet count. However we need
to monitor her condition for any warning signs such as :
Mrs. Norelinah need to be on daily follow up until her platelet count reach the targeted value which is 200
and her symptoms improved.
The patient with need to always update her Dengue Monitoring Record.