Case Presentation

Bareth A/L Ravindran

 Patients Details
Name : M
Age : 14
Sex : Male
Race : Suluk
Religion : Islam
Address : Taman Bahagia, Sandakan
Marital status : Single
Occupation : Student
DOA : 25th April 2017
Date of Clerking : 25th April 2017

*no preexisting comorbidities

 Chief Complaint
1. Fever for 6 days
2. Abdominal pain for 3 days
 History of Presenting
Illness
1. Fever
.Sudden onset of high grade fever, with
chills and rigor.
.Continuous in nature.
.No relieving or exacerbating factors.
.Associated with headache, dizziness,
muscle aches and pain, loss of appetite,
nausea and vomiting.
 History of Presenting
Illness
2. Abdominal pain (3 days after the fever)
.Sudden onset of abdominal pain
.At the umbilicus
.Dull and colicky in nature.
.There is no radiation elsewhere.
.There are no relieving or aggravating
factors.
.He rated the pain as 4/10
 History of Presenting
Illness
3. Headache
.Frontal
.Throbbing in nature and occurs
intermittent about 3-4 times a day with
each episode around 20-30 minutes.
.There is no radiation elsewhere.
.It is relieved by sleep and aggravated by
activity.
.The pain score given is 4/10.
 History of Presenting
Illness
4. Vomiting
.About 2-3 episodes daily.
.Contents of the vomitus are usually watery
with food particles and occasionally billous.
.There is no blood in the vomitus.
.No known triggers, no exacerbating or
relieving factors.
.The last episode of vomiting was 2 days
ago.
 History of Presenting
Illness
He lives in a dengue endemic housing
area with frequent fogging.
There is no diarrhea, no skin rashes, no
mucosal bleeding and no retro-orbital
pain.
There is no history of recent travel to the
jungle/forests or bathing in
rivers/waterfalls.
 History of Presenting
Illness
22/4/2017
(Saturday
evening)
No 23/4/201
improvement. 7
Brought to (Sunday)
the same Onset of
clinic. Given abdomina
an injection. l pain

20/4/2017 21/4/2017 25/4/2017

(Thursday (Friday (Tuesday
Slight morning)
Evening) Morning)
relief of Brought to OPD
Sudden Brought to
fever due to
onset of private
fever clinic, persistent fever
given and abdominal
Paracetam pain.
Admitted into
 Systems Review
1. Central nervous system:
No seizure, no delusion, no loss of
consciousness, no loss of memory, no change
in visual audio and taste sensation, no
numbness, no paralysis, no vertigo, no
tinnitus.
2. Cardiovascular system:
No palpitation, no chest pain, no dyspnea, no
paroxysmal nocturnal dyspnea, no orthopnea,
no ankle swelling
3. Respiratory system:
No cough, no sputum, no hemoptysis, no
wheezing, no hoarseness, no night sweat, no
flu, no tuberculosis contact.
 Systems Review
5. Genitourinary system:
No hematuria, no dysuria, no hesitancy, no
dribbling, no frequency, no urgency, no
polyuria, no incontinence, no loin pain, no
urethral discharge, no nocturia.
6. Hematological system:
No easy bruising, no lumps and bumps.
7. Endocrine system:
No heat or cold intolerance, no polyuria, no
polydipsia, no polyphagia, no neck swellings.
 Past Medical History

This is his first hospitalization.

He has no history of medical illnesses or
any childhood illnesses.
 Past Surgical History
No surgeries done previously.
 Allergy and Drug History
He has no known food and drug allergy.
He is not on any long term medications
or supplements nor does he take any
traditional medication.
Currently, receiving IV 0.9% sodium
chloride infusion and Paracetamol 1g
QID.
 Family History
45 43

12 9 7
 Family History
There is a possible history of infectious
contact as his father had a low grade
fever two days before him but made a full
recovery afterwards.
All other family members do not have
fevers and are well.
There is no family history of systemic
illness such as hypertension, diabetes
mellitus and hyperlipidemia.
There is no family history of malignancy.
 Social History
He is a Form 2 student at SMK Taman Fajar.
A non-smoker and does not take any alcoholic
beverages.
Active young man, who plays sports such as
football and badminton.
There is no use of mosquito nets, mosquito coils
or mosquito repellents at home.
No potential areas for stagnant water such as
potted plants or bath tubs.
The drains at his housing area have poor
drainage as they are frequently clogged with
rubbish.
 Summary
A 14 year old teenager presented with
fever for 6 days and abdominal pain for 3
days.
The fever is high grade and associated with
chills and rigor.
Other associated symptoms are frontal
headache, generalized myalgia, dizziness,
loss of appetite, nausea and vomiting.
He lives in a dengue endemic housing area.
 General Examination
The patient is lying supine on the bed,
with a pillow supporting the head.
He appears to be well-built and does not
appear to be ill-looking nor dehydrated.
He is conscious and alert to time, place
and person.
He is not in pain or respiratory distress.
There is a green cannula inserted at the
dorsum of the right hand and an IV line
being infused with normal saline.
Peripheries are warm and the capillary
 General Examination
On general inspection of the upper limbs,
there is no clubbing, no nail changes of
the hand, no stigmata of infective
endocarditis, no peripheral cyanosis, no
palmar pallor, no drug injection sites and
no skin rashes seen.
There are no petechial haemorrhages
seen.
On inspection of the face, there is no
jaundice and no abnormal facies
On inspection of the oral cavity, there is
no central cyanosis, oral ulcers or oral
thrush, no bleeding gums and the tonsils
 General Examination
Lastly, there is no pedal edema and no
palpable lymph nodes.
 Vital Signs
1. Heart rate: 78 beats per minute,
regular rhythm, normal volume, no
radial-radial delay.
2. Respiratory rate : 22 breaths per
minute
3. Blood pressure : 120/72 mmHg
4. Temperature : 37.5 degree Celsius
 Abdominal Examination
1. Inspection: Abdomen moves with
respiration, umbilicus is centrally
located and inverted, no abdominal
distension, no scars, no swelling, no
visible peristalsis, no visible pulsation,
flanks are not full and the hernia
orifices are intact.
2. Palpation: Abdomen is soft. There is
tenderness at the umbilical region.
Otherwise, there are no palpable
masses, no hepatosplenomegaly and
the kidneys are non-ballotable.
 Cardiovascular
Examination
Inspection: No scars seen, no chest
deformities and no visible pulsations
seen over the praecordium.
Palpation: Apex beat is felt at 5th
intercostal space at level of mid-
clavicular line, no parasternal heaves, no
palpable P2 and no thrills.
Auscultation: First heart sound is followed
by second heart sounds heard over all
heart areas, no added sounds.
 Chest Examination
Inspection: Chest expansion was bilaterally
equal. No deformity, no scar, no use of
accessory muscles
Palpation: Trachea is not deviated. The chest
expansion is bilaterally equal. The tactile
fremitus is equal bilaterally.
Percussion: Resonant bilaterally equal
throughout the lung field except over the
liver and heart areas.
Auscultation: Vesicular breath sounds heard
bilaterally with no added sounds.
 Neurological Examination
A. Upper limbs
.Inspection: No wasting of the muscles of the upper
limb, no limb deformities, no asymmetry, no
neurocutaneous stigmata, no fasciculations and
tremors seen.
.Tone: Tone is normal on both upper limbs.
.Power: Grade 5 for all muscle groups, symmetrical for
both upper limbs.
.Reflexes: Normal biceps, triceps and supinator
reflexes on both upper limbs.
.Sensory examination: Fine touch, joint proprioception
and crude touch components are intact bilaterally.
 Neurological Examination
B. Lower limbs
.Inspection: Gait is normal. There is no wasting of
muscles, no neurocutaneous stigmata, no
fasciculations and tremors seen over the lower limb.
.Tone: Tone is normal for both limbs.
.Power: Grade 5 for all muscle groups of both lower
limbs.
.Reflexes: Normal knee and ankle jerk on both lower
limbs.
.Sensory examination: Fine touch, joint
proprioception and crude touch components are
intact bilaterally.
 Neurological Examination
C. Cranial Nerves
.All cranial nerves function are intact.
 Summary
On general examination, the only
significant finding is an elevated body
temperature (37.5 degree Celsius).
For abdominal examination, tenderness
at the umbilical region was elicited.
 Provisional Diagnosis
Dengue fever with a warning sign as the
patient fulfills the criteria of probable dengue
which are:
i. Lives in a dengue endemic area
ii. Presentation with high grade fever with
chills and rigor.
iii. Fever that is associated with generalized
myalgia, nausea and vomiting.
iv. One warning sign which is abdominal
pain/tenderness.
 Differential Diagnosis
1. Malaria
A. Points for:
. Presentation with high grade fever with chills
and rigor, with associated symptoms such as
headache, generalized myalgia, dizziness, loss
of appetite, nausea and vomiting, abdominal
pain.
. Malaria is a tropical disease endemic in Sabah.
B. Points against:
. The pattern of fever in this patient is continuous
in nature, whereas in malaria, the pattern of
fever is usually paroxysmal/intermittent.
. No history of jungle trekking or recent travel to
forests which are usual places where biting by
 Differential Diagnosis
2. Leptospirosis
A. Points for:
.Presentation with high grade fever with
chills and rigor, with associated
symptoms such as headache, generalized
myalgia, dizziness, loss of appetite,
nausea and vomiting, abdominal pain.
B. Points against:
.Again, the most important differentiating
feature is the pattern of fever. In
leptospirosis, the pattern of fever is
usually biphasic.
 Diagnostic Investigations
1. Dengue rapid antigen testing and
dengue serology
To confirm the diagnosis of dengue fever. In
this patient, NSI antigen is positive,
accompanied by positive IgM, which
indicates primary dengue infection.
2. Blood smear for malarial parasite
To look for malarial parasites in thick and
thin blood smears in order to establish the
diagnosis of malaria. Not done for this
patient.
3. Rapid ELISA test, Microscopic
Agglutination Test (MAT) and blood
 Supportive Investigationa
1. Full blood count (FBC)
.To look for leukopenia (with or without
relative neutropenia) thrombocytopenia
and increased haematocrit that is
characteristic of dengue fever.
.In malaria, there is relatively normal white
blood cell count but with lymphopenia.
.In case of leptospirosis, there will be
leukocytosis
Parameters Result Unit References range

WBC 3.25 103/ uL 4.0 - 10.0

RBC 4.7 106/ uL 3.4 - 4.8

HGB 13.9 g/ dL 12.0 - 15.0

HCT 44.2 % 36.0 - 46.0

MCV 90.0 fL 83.0 - 101.0

MCH 29.0 pg 27.0 32.0

MCHC 34.3 g/ dL 31.5 34.5

PLT 64.7 103/ uL 150.0 - 410.0

RDW 43.8 fL 39.0 - 46.0

MPV 10.6 fL 6.9-10.6

Neutrophils % 41.3% % 40.0 - 80.0

Lymphocyte % 30.0 % 20.0 40.0

Monocyte % 8.0 % 2.0 10.0

Eosinophil % 3.0 % 1.0 6.0

Basophil % 0.1 % 0.1 -2.0

Neutrophils # 1.35 103/ uL 2.0 7.0

Lymphocyte # 2.17 103/ uL 1.0 3.0

Monocyte # 0.552 103/ uL 0.2 1.0

Eosinophil # 0.0 103/ uL 0.02 0.5

Basophil # 0.03 103/ uL 0.02 0.1

 Supportive Investigations
2. Liver function test (LFT)
.Can be done to assess the severity of the
disease and organ impairment.
Parameters Results Unit Reference
Range
Total 3.6 Umol/L 3.4-20.5
Bilirubin
ALT 21 U/L 0-55
AST 34 U/L 5-34
ALP 145 U/L 40-150
Total 80 g/L 64-83
Protein
Albumin 48 g/L 35-50
 Supportive Investigations
3. Renal function test (RFT)
.To look for any electrolyte imbalances as
the patient has been vomiting.
Parameter Result Unit Referenc
e range
Na 140 mmol/L 136-145
K 4.9 mmol/L 3.6-5.1
Cl 105 mmol/L 98-107
Urea 5.5 mmol/L 2.5-7.2
Creatinine 80.0 umol/L 50-98
 Supportive Investigations
4. Acute phase reactants: ESR and CRP
.Can be done but it is non-specific as they
may be raised in all conditions of active
inflammation. Not done for this patient.
5. Coagulation profile
.To exclude any coagulopathy in case of
severe haemorrhage and mucosal bleeding.
Not done for this patient as he has not
manifested any bleeding tendencies.
 Imaging
1. Ultrasound of the abdomen
.To look for clinically undetected
hepatosplenomegaly and any fluid collection
in the pleural space, abdominal cavity or
pericardial space. Not done for this patient.
2. Chest X-Ray
.To look for pleural effusion caused by
plasma leakage in dengue fever. Not done
for this patient.
 Final Diagnosis
Confirmed primary dengue fever with
one warning sign (abdominal
pain/tenderness).
 Management
1. Start IV 0.9% sodium chloride infusion at a
rate of 2ml/kg/hour (2x45kg=90ml/hour).
2. Encourage oral intake of fluids.
3. Dengue charting and strict input/output
charting.
4. Start the patient on T.Paracetamol 1g QID.
5. Look out for any further warning signs.
6. Daily FBC, LFT and RFTs.