Lopez, Lovelle

Patient’s Name: AC
Gender: Male
Address: Butuan City
Religion: Catholic
Time interviewed: August 02,2019

Chief complaint: Fever

Present Health history

4 days prior to admission patient had onset of intermittent fever, high documented was 38’c
associated with nausea, loss of bowel movement, generalized body malaise and chills. Patient took
advil.

2 days prior to admission, above symptoms persisted now associated with dry cough and colds,
sought consult with an attending physician in butuan and was given with Tylenol with relief.

1 day prior to admission, above symptoms persisted, sought consult again with an attending
physician in butuan result revealed, increase hematocrit, thrompocytopenia, leukopenia and
positive for dengue quadro test, negative for typhoid fever, hence was transferred here for further
evaluation and management.

Past medical history

There is not hypertensive, diabetes mellitus or bronchial asthma. Patient is known to have typhoid
fever since he was 9 years old. Patient underwent appendectomy when he was 4 years old. There
is no food and drug allergy.

Family History

Parents are both alive with unremarkable history.

Social history

Patient is working as a manger on their own family business. He is a graduate of business in

management. He is the eldest among 3 siblings. He doesn’t have any regular exercise. His diet
mainly composed of chicken, pork, rice and rarely consumed vegetables. He is non-smoker and
non-alcoholic drinker.

Review of system

In general, patient doesn’t have any weight loss or weight gain. Patient also noted body malaise.
However, he did not notice any insomnia and anorexia. There are no rashes. He did not feel any
heat-cold intolerance or palpitation. There is no visual dysfunction, lacrimation or eye itching. For
his ears, there is no tinnitus, discharges or pain noted. As well as, there is no epistaxis or nasal
obstruction. He did not experience any bleeding gums, rose spots or dental problem. There is no
chest pain noted. For the gastrointestinal, he doesn’t have any melena, hematochezia, hematemesis
or change of bowel movements. He doesn’t have any dysuria, polydipsia and polyuria. There is no
arthralgia or arthritis. Prevalent of dengue in their area in butuan.

Physical Examination
Patient was received at the emergency room, weak looking, awake, conscious, responsive and
coherent

Vital signs
Blood pressure 95/60 mmhg, normal
Temperature 37.4 degree Celsius, afebrile
Pulse rate 85 beats per minute, tachycardic
Respiratory rate 20, eupneic
Oxygen saturation 98%

Anthropometric measurement
Height: 169 centimeters
Weight: 70.90 kilogram
Body mass index:

The skin is brown in complexion. There is no visible lesions, jaundice or pallor. It is warm to
touch.

The head is normocephalic and hair is black and evenly distributed. There are no lesions or masses
noted.

The eyes are brown, with anicteric sclera and pinkish palpebral conjunctiva. Pupils are round and
equally reactive to light. There are no discharges or periorbital edema noted.

The ears are symmetrical in size and shape. There are no lesions or masses noted on both ears.
There are no palpable post-auricular lymph nodes.

There is no nasal flaring or discharge noted. Both nares are patent. Absence of tenderness of the
sinuses upon palpation.

There are slightly dry lips and oral mucosa with no lesions. The tongue is at midline. Tonsils are
not swollen and uvula in the midline.

Upon inspection, there is no neck vein engorgement, scars or lesions noted. Neck is supple with
normal range of motion. There are no palpable cervical lymph node.
There is symmetrical chest expansion. There is no masses or crepitation noted. Both lung fields
were resonant upon percussion. Clear breath sounds on both lung fields.

Point of maximal impulse is 5th intercostal space and midclavicular line with adynamic
precordium. There were no heaves or thrills noted upon palpation. Normal cardiac rate and rhythm
with no murmur noted.

Upon inspection of the abdomen, it is globular in contour, soft and non-tender There was
normoactive bowel sound at 10 per minute. Upon percussion, tympanic in all quadrants.

For the genitourinary, patient refused to be examined. But upon palpation of the bladder, there
were no tenderness or masses noted.

There were full and equal pulses on both upper and lower extremities. There was normal range of
motion. Capillary refill time was less than two seconds.

The sense of smell is intact. Both pupils constrict when light is shone. The extraocular muscles are
intact. The muscles of mastication are intact. The face is symmetric and patient was able to smile
and frown the patient able to hear whispered voice at a distance of 2 feet. He was able to shrug and
raise shoulders. He was able to stick out tongue and move it sideways. The motor was 5/5 on both
upper and lower extremities. There were an intact and pain sensations. The reflexes were 2+ on all
extremities. There was no Babinski sign.

Impression: Dengue fever with with warning signs

Differential Diagnosis

Dengue fever, included since patient presented with fever, loss of bowel movement, nausea, chills
and generalized body malaise. However cannot totally rule out.

Chikungunya, included since patient presented with fever, loss of bowel movement, however
excluded since patient did not present with any arthralgia, arthritis or rash.

Typhoid fever, included since patient had history of typhoid fever, highest temperature recorded
was 39’c, however exluded since no rose spot, splenomegaly, abdominal pain.

Final Diagnosis: Dengue fever with warning signs

Discussion

Dengue fever with warning signs since patient showed there is increase in hematocrit with platelet
slowly decreasing.
Dengue fever is a mosquito-borne infection. Outbreaks often start during the rainy season when
the mosquito vector, Aedes aegypti, is abundant. The mosquito breeds in water- holding
receptacles (desert coolers, vases, discarded containers, coconut husks, or old tires) or in plants
close to human dwellings. The reservoir of infection is both man and mosquito. The female
mosquito acquires the virus by feeding on an infected human with viremia. After a period of 1 to
2 weeks, the mosquitoes are infective and remain so for their entire life span of 1 to 3 months. In
this period, they infect other humans during a blood meal.

Typically patients present with sudden onset fever, headache, retro-orbital and back pain, along
with severe myalgia, giving rise to the popular term “breakbone fever.” Individuals of all ages and
both sexes are susceptible to dengue fever. Patients also have a macular rash, lymphadenopathy,
and palatal vesicles. The illness usually lasts for 1 week. Additional symptoms usually include
anorexia, nausea, and vomiting. Epistaxis and scattered petechiae are commonly seen in
uncomplicated dengue. Pre- existing gastrointestinal lesions may bleed during the acute ill- ness.
Dengue hemorrhagic fever is a severe form of dengue fever caused by infection with more than
one serotype of dengue virus. The initial infection sensitizes the patient and the subse- quent
infection by the second serotype invokes a severe hyper- sensitivity reaction leading to increased
plasma capillary leakage and hemostatic derangement. Patients manifest clinically with severe
bleeding and shock. Dengue hemorrhagic fever has a high mortality rate.