Iloilo Doctors’ Hospital, Inc.

Department of Internal Medicine

MCC San Antonio, Danniel D. January 20, 2022

I. General Data

This is the case of M.X., 32 year old, Male, Single, Filipino, and was born in Villa Arevalo,
Iloilo City. This is the patient’s first admission.

II. Chief Complain

Fever

III. History of Present Illness

2 days prior to admission, patient experienced an on and off fever which was intermittent
in description, highest recorded temperature was at 38.9OC in the afternoon. Fever was
associated with body malaise, myalgia, rash on the abdominal area. Fever was alleviated by self –
medicating with paracetamol.
1 day prior to admission, fever persisted with headache and abdominal pain with a pain
scale of 5/10.
On the day of admission, above symptoms persisted with an increase in severity of
abdominal pain from 5 to 7/10 and loss of appetite. No other associated symptoms noted.

IV. Past Medical History

Childhood immunizations unrecalled. No allergies noted. No surgical history noted. No

maintenance medicines. No history of travel outside of Panay island.

V. Family History

Patient claimed to have no heredo – familial disease (DM, HTN, Asthma, etc.). Patient’s
mother claimed to be well.

VI. Personal History

Patient works as a private driver. Non alcoholic drinker and non smoker. Patient is fond of
eating street food. Stool output is normal. Patiient drinks 8 glasses of water a day as claimed.

VII. Socioecononomic History

Patient lives in a non – congested rural area with his mother. No illnesses in the
community noted. Presence of stagnant water in the house noted. Patient takes care of cows
without using ppe. Patient also claims to have domestic animals as pets.
 VIII. Physical Examination

General Survey

Patient was ambulatory, coherent, conscious, not in cardiopulmonary distress, and oriented to
time, place, and person.

Vital Signs Value Normal Value Remarks

Temperature 37.8 O C 36.6 – 37.5 O C Febrile
Heart Rate 98 bpm 60 – 100 bpm Normal
Respiratory Rate 22 cpm 12 – 20 cpm Tachypneic
Blood Pressure 110/70 mmHg <120/<80 mmHg Normal

Anthropometric Data

Height 177.8 cm
Weight 79.5 kg
25.15 kg/m2
BMI Patient is obese 1.
(Asian BMI classification)

SKIN
Inspection: Petechial rashes on the abdomen noted.
Palpation: Warm to touch, good skin turgor, capillary refill at <2 seconds.

HEENT
Mouth: Lips are pinkish, moist without lesion, no swelling, pinkish without bleeding. Tonsils non –
hyperemic and non swollen.
Eyes: No sunken eyeballs. Pinkish conjunctiva, no conjunctiva. Anicteric sclerae.
Neck: No thyroid enlargement. No neck vein engorgement. JVP measured at 7 cm. No
lymphadenopathy.Trachea at midline and thyroid at midline.

CHEST & LUNGS

Inspection: No chest deformities noted. No usage of accessory muscles of respiration.
Palpation: Symmetrical chest expansion. Equal tactile fremitus.
Percussion: All lung fields of both lungs are resonant.
Auscultation: Bronchovesicular in all lung fields.

CARDIOVASCULAR
Inspection: Adynamic precordium
Palpation: PMI at 5th left ICS MCL
Auscultation: Regular rate and rhythm. No murmurs or extra heart sounds heard.

ABDOMEN
Inspection: Flat abdomen. No scars, ulcers, prominent veins, striae, or masses seen.
Auscultation: Normal bowel sounds heard. No aortic, renal, or iliac bruits heard.
Percussion: Tympanitic on all quadrants.
Palpation: Liver span measure at 11 cm MCL and 7 cm midsternal. (-) kidney punch test.

EXTREMITIES
Inspection: No active lesions noted. No clubbing of nails. No edema.
Palpation: (+) Tourniquet test. 5/5 MMT on all extremities.
SALIENT POINTS

Pertinent Positives Pertinent Negative

No bleeding, edema, cough, vomiting, diarrhea,
32 y.o. male
jaundice, calf pain, conjunctival suffusion, dysuria
Fever (intermittent, 2 days, peak at 38.9) No history of wading in flood
Diffuse abdominal pain No illnesses in the community noted
Body Malaise Warm to touch, good skin turgor
Back Myalgia (-) Kidney Punch
Headache
(+) Stagnant water present in the house
Petechial rashes on the trunk

Admitting Impression

Dengue with warning signs

Differentials:
- Typhoid fever
- Leptospirosis
- Acute pyelonephritis
- COVID – 19

Approach to arrive at the diagnosis:

The patient came in and presented with fever. A normal body temperature is ordinarily maintained
despite environmental variations because the hypothalamic thermoregulatory center balances the excess heat
production derived from metabolic activity in muscle and the liver with heat dissipation from the skin and lungs.
Fever is defined as an A.M. temperature of >37.2OC or a P.M. temperature of >37.7OC. Pyrogens are used to
describe substances that causes fever; exogenous pyrogens are derived from outside the patient like most
microbial products, microbial toxins, or viruses. On the day of admission, patient came in due to fever with
associated diffuse abdominal pain with a pain scale of 7/10, and loss of appetite. 2 days prior to admission,
patient had intermittent fever with the highest temperature recorded associated with headache, body malaise,
and myalgia. Physical examination findings that were remarkable include the patient having petechial rashes
found on the abdomen. History and physical examination narrowed the differential diagnosis to Dengue with
warning signs and Typhoid fever. Leptospirosis cannot be ruled out from this patient at it warrants diagnostic
testing (Urine culture, CBC, liver function test). Acute pyelonephritis was entertained in this patient as the
patient exhibited high documented fever, abdominal pain, and back myalgia; but usually, the diagnosis of acute
pyelonephritis, almost always has a positive kidney punch test but in this patient, it was negative, further
diagnostic testing is warranted. COVID – 19 was entertained in this patient due to fever and myalgia and also in
our present setting today where cases are rising and the ymptoms of covid 19 like fever, myalgia, headeache,
and rashes (which are uncommon) are experienced by the patient.
 Diagnostic Flow Sheet

1. Complete Blood Count

Since the patient presented with fever, cbc is warranted. CBC can suggest and narrow down the
differentials since it can detect deviances from different components of the blood.

Results Normal Value

RBC 5.11 4.2-6.0x10^12/L
WBC 4.31 4.5-11.0x10^9/L
NEUTROPHIL 0.80 0.50-0.70
LYMPHOCYTE 0.10 0.22-0.40
MONOCYTE 0.07 0.03-0.08
EOSINOPHIL 0.03 0.01-0.04
BASOPHIL - -
HGB 148 135-180g/L
HCT 0.45 0.40-0.54L/L
OTHERS MCH: 29.00 MCH: 26-34 pg
MCV: 87.40 MCV: 80-100 fl
MCHC: 33.20 MCHC: 32-36 g/dL
Platelet count: 164 Platelet count: 150-450
10^9/L

Interpretation: Sinus rhythm, normal axis with ST segment depression at anteroapical wall and
myocardial ischemia.

2. Dengue IgM and IgG

Dengue NS1 is an immunoassay for the detection of non – structural protein 1 antigens; aids in the
diagnosis as early as 1 day post – onset of symptoms. IgM antibody is usually detected by day 5 of illness
while IgG antibody is detected past dengue infection.

Results
NSI Ag (+)
Dengue IgM (-)
Dengue IgG (-)

Since the patient is (+) with Dengue NS1, it is confirmed that the patient has dengue.
3. Urinalysis

Since the patient presented with fever, and our primary consideration is an infectious case, urinalysis
was requested to detect urinary tract infections, kidney disease, diabetes, etc.

Macroscopic examination: Microscopic examination Range Grade

Color: Straw WBC pus cells 1-2/hpf Occasional
Transparency: Hazy RBC 1-3/hpf Occasional
pH level: 6 Epithelial cells:
Reaction: Acidic Squamous cells - few
Specific gravity: 1.015 Crystals - amorphous urates - occasional

Chemical examination:
Sugar: NEGATIVE
Bilirubin: NEGATIVE
Ketone: NEGATIVE
Blood: NEGATIVE
Albumin: NEGATIVE
Urobilinogen: NEGATIVE
Nitrite: NEGATIVE
Leukocytes: NEGATIVE

4. Serum Electrolytes

Electrolytes are requested to check for any electrolyte imbalances. Both serum electrolytes were
normal; no signs of dehydration.

Electrolytes
Na 143 mmol/L 136 – 145 mmol/L
K 3.86 mmol/L 3.5 – 5.10 mmol/L

5. SARS – CoV – 2 RT PCR/RAPID ANTIGEN

Since we are in a pandemic, hospital protocols require a patient to have an RT PCR test before
they can be managed by the institution about their present illness. The patient’s RT PCR and
Rapid antigen were both negative, along with out history, we can rule out COVID-19.

SARS-CoV-2 RTPCR (-)

SARS-CoV-2 Rapid Antigen (-)
6. Chest X- ray

This is the chest x-ray of patient M.X. 32 years old with a diagnosis of dengue, taken on
admission, AP view. Good visualization, good inspiratory effort, good exposure, no rotation. Trachea is
midline. No fractures and lytic lesions noted. CR ratio of 0.5, no blunting of cardiophrenic and
costophrenic angles. No infiltrates noted.
 Therapeutic Flow Sheet
Name, Dosage and Mechanism of Action
Route of Drug
Omeprazole Omeprazole is a
substituted benzimidazole
gastric antisecretory agent
and is also known as
proton pump inhibitor
(PPI). It blocks the final
step in gastric acid
secretion by specific
inhibition of adenosine
triphosphatase (ATPase)
enzyme system present on
the secretory surface of the
gastric parietal cell. Both
basal and stimulated acid
are inhibited.
2. Paracetamol Paracetamol exhibits
analgesic action by
Adult: 0.5-1 g 4-6 peripheral blockage of pain
hourly. Max: 4 g impulse generation. It
daily. Oral produces antipyresis by
inhibiting the hypothalamic
heat-regulating center. Its
weak anti-inflammatory
activity is related to
inhibition of prostaglandin
synthesis in the CNS.
(MIMS)
3. Multivitamins This nutritional supplement
1 cap OD is formulated typically with
vitamins A, C, E and zinc to
help enhance the body's
natural immune function
and help improve body
resistance against illness
and infections. These
nutrients are also known to
help the body's antioxidant
defense system against
damaging free radicals.
Indication for the Special Considerations
Patient and Responsibilities
Help relieve the Patient with reduced
patient’s abdominal body store or risk
pain factors for reduced
vitamin B12 absorption;
risk of osteoporosis.
Hepatic impairment.
Children, elderly.
Pregnancy and
lactation. CYP2C19
ultrarapid metabolisers
helps to relieve pain When taking
and fever paracetamol, do not
exceed the maximum
dosage stated on the
packet or patient
information leaflet.
Excessive paracetamol
use can result in severe
damage to the liver
Nuutritional Overdosage:
supplement Vit. A must not exceed
10,000 IU or weekly
intakes in excess of
25,000 IU as it may
cause blurred or double
vision, dizziness,
drowsiness, headache,
insomnia, lack of
muscle coordination,
seizures, papilledema,
raised intracranial
pressure
Vit. C: In excess of 2 g
per day may lead to
nausea, abdominal
cramps, diarrhea, and
nose bleeds. Elevated
serum glucose levels, GI
obstruction, and
esophagitis. In people
with kidney disease,
excess vitamin C also
may contribute to
oxalate-containing
kidney stones. In
healthy people,
epidemiological studies
do not support an
association between
excess vitamin C intake
and kidney stones.

Vit. E: Vitamin E toxicity

is rare, but occasionally
high doses cause a risk
of bleeding, as well as
muscle weakness,
fatigue, nausea, and
diarrhea.

Zinc: Signs of acute zinc

toxicity (doses > 200 mg
daily) include GI
pain/cramps, nausea,
vomiting, and diarrhea,
loss of appetite,
headache, lethargy,
muscle pains, and
fever.
 Case Discussion

Fever is not only caused by infections but it can also be a manifestation in the absence of
microbial infection. Release of pyrogenic cytokines induce fever. Infection, microbial toxins, mediators of
inflammation, immune reactions activate monocytes/macrophages, endothelial cells to release
pyrogenic cytokines IL-1, IL-6, TNF, and IFN into the circulation, this is sense by the brain and begins to
elevate the levels of prostaglandin E2 in the hypothalamic tissue and third cerebral ventricle. The
increase in PGE2 in the periphery accounts for the nonspecific myalgias and arthralgias that accompany
fever. PGE2 release trigger the PGE2 receptor in glial cells which leads to the release of cyclic AMP which
then elevates the elevated thermoregulatory set point which causes conservation and production of heat
which subsequently causes fever.

Dengue virus is a flavivirus and exists in four serotypes (DENV1–4) that circulate independently of
one another; immunity to one serotype does not confer immunity to the others. It is transmitted
primarily by Aedes aegypti and secondarily by Aedes albopictus. The life cycle of dengue virus consists of
sylvatic transmission from mosquitoes to nonhuman primates and back to mosquitoes. Aedes is able to
breed in standing water associated with human habitation, such as cisterns, ornamental ponds, puddles,
and water trapped in abandoned tires. In this case, the patient claimed to have presence of stagnant
water in their house which is one of the pertinent positives and one of the reasons why dengue fever is
the admitting impression. After the incubation period (4-7 days), the illness begins abruptly and will be
followed by 3 phases: Febrile phase, critical phase, and recovery phase.

Dengue hemorrhagic fever consists of the following: fever or history of 2-7 days, and hemorrhagic
tendencies (at least one or more of a positive tourniquet test, petechial, ecchymosis, purpura, bleeding
from the mucosa, GIT, or injections site, hematemesis, melena, thrombocytopenia, and evidence of
plasma leakage due to increased vascular permeability. In this patient, 3 day history of fever with the
highest recorded fever of 38.9 degrees Celsius was noted, along with headache, back pain, body malaise,
abdominal pain, and loss of appetite. Pertinent PE findings include patient being febrile upon admission,
petechial rash found on the abdomen, and a positive tourniquet test.

The patient is currently in the febrile phase of dengue fever since he was tested with Dengue NS1
and got a positive test which confirms the diagnosis of dengue with warning signs. Both IgM and IgM
were found negative as antibodies usually take 2 weeks to be detected. Upon cbc, patient also exhibited
a low white blood cell count. Other laboratory tests done were normal. The patient was classified as
dengue with warning signs group b which warrant inpatient management, he was not placed on group c
since there were no evidence of severe plasma leakage, severe bleeding, and severe organ impairment of
the patient.
 Management

Management of Group B dengue fever with warning signs include hydrating the patient with oral
fluid therapy if the patient can tolerate it but if not, IVF should be started.
IVF should start with 5-7 ml/kg/hr for 1-2 hours then reduce to 3-5 ml/kg/hr for 2 – 4 hours,
assess the patient’s clinical response and then if improving, reduce again to 2-3 ml/kg/hr.
- If hct remains the same or rises minimally, continue with 2-3 ml/kg/hr for another 2 – 4 hrs; if with
worsening of vitals and rapidly increasing HCT, increase rate to 5-10 ml/kg/hr for 2 hours. Reduce IVF
until adequate UO and/or fluid intake or hct decreases below the baseline value.

In monitor for this group, vital signs should be checked every 4 hours until our of critical phase,
monitor hct at baseline and q6-12 hrs and also monitor blood glucose and other organ function test.
Discharge Criteria:

All must be present:

- No fever for 48 hours
- Improvement of clinical status
- Increasing trend of platelet count
- Stable hct without IV fluids.

Dengue fever is always going to be present in our country since we are located at near the equator making
us a tropical country where mosquitoes that carry dengue virus breed. So, it is important that we always remind
and explain to our patient’s the strategy in combatting against dengue which consists of the 4s, Search and
destroy, Self – protection, Seek early consult, and say no to indiscriminate fogging. Always remember that the
first step to prevent dengue is within our homes which in this patient, failed to do.