INTERNAL MEDICINE CASE REPORT

LAMA, SHRADDHA GROUP-5A

General data
This is a case of A.H.M 42 year old, MALE, Filipino,
MARRIED,Catholic.

Chief complaint:
Fever intermittent

History of present illness

4 days prior to consult the patient had undocumented fever with
easily fatigue and no other associated symptoms of vomiting,
abdominal pain, dizziness and headache. The patient self medicated
with paracetamol 500mg which provided him with temporary relief.
1 day prior to consult the patient experienced bloatedness and
seeked consult in a private hospital. The patient had his CBC and
platelet count which revealed 148,000 and UA was done and was
diagnosed with UTI. The patient was prescribed with with co-
amoxiclav of 625mg/tab.
Few hours prior to consult the patient has persistence of symptoms
and consulted in a private clinic where low platelet count of 42,000
was revealed. The patient consukted in our institution. Hence
admission.

Past medical history:

patient had an unrecalled surgery when he was 2 years old on the
left buttock.
The patient is not hypertensive, diabetic and has no asthma.

Family history:
Patient both maternal and paternal side has diabetic, with no history
of hypertension, cancer or heart disease.

Personal and social history

Patient is a smoker 15 paks/year and an occasional alcohol drinker
and denies of any illicit drug use.

Review of system:
Skin: Warm, moist, no pallor, no jaundice, good skin turgor,no
rashes
HEENT: Anicteric, pink palpebral sclera, no aural discharge, nasal
septum midline, no nasal discharge
Chest: No hemoptysis, no cough,symmetrical chest expansion
Heart: No chest pain,clear breath sounds,no murmur
Abdomen: soft ,non tender ,globular, no scars,
Extremities: No edema, no muscle pain, no joint pain,macular lesion
all over the back.
Physical examination
General Survey: Conscious, coherent and not in cardiorespiratory
distress
Vital signs: T-36, HR 76, R-2, BP- 100/70
Skin: Warm to touch, moist with good skin turgor, (+) upper
extremities rashes
HEENT: Anicteric, pink palpebral sclera, no aural discharge, nasal
septum midline, no nasal discharge,
Chest: Symmetrical chest expansion, no retractions, (-) crackles
Heart: Adynamic Precordium; normal rate , regular rhythm; no
murmurs
Abdomen: flat, normoactive bowel sounds, soft, tender abdomen
DRE: not assessed
Extremities: (-) edema, (-) cyanosis, (+) rashes on the upper
extremities

Course in the ER
History was taken and physical examination was done. Vitals signs
were taken and recorded. The patient was given ivf of pnss 11x 16
hours, vitamin C 150mg/tan and paracetamol 500mg/tab.
Laboratory was requested of CBC,
PC, CREA, ALT ,blood typing and DENGUE NS1, DENGUE IgG,
DENGUE IgG

Admitting diagnosis:
DFS WITH WARNING SIGNS
UTI

Course in the wards:

Day1 ( 02/12/17)
The patient was awake ,no DOB, no chest pain ,no Abdominal pain.
With vital signs of BP:100/70 PR: 78 RR:
20 TEMP: 36.8

with normal PE of PINK,PC,(-) TPC,(-) CC AD, SCE, (-)crackles, Soft ,

nontender ,no mass, no edema ,(+) FEPP.

The lab results of CBC: WBC 8,080/HGB 16.43 /HCT 48.74 /SEG 45/
LYM 31/ MONO 19/ EOS 3/ BASO 2/ PC 53,000/RBC 5.48/MCV 88.93/
MCH29.98/MCHC 33.71
ALT 280.6
BLOOD TYPEING A+
DENGUE NS1 POSITIVE
DENGUE IgG NEGATIVE
DENGUE IgG NEGATIVE

Medication:
Silymarin 140mg/tab OD, tramadole+paracetamol 1 tab BID,
levofloxacin 500mg/tab OD, Omeprazole 40mg IV OD and disfityl 1
tab TID.

Diet: dat exccept dark colored foods

Ivf: pnss 1l x 16 hrs
CPC PC MONITORING Q12

Day 2(02/13/17)
The patient was awake ,no DOB, no chest pain ,no Abdominal pain
with vital signs of BP:100/70 PR:80 RR:20 T: 36.5 Normal PE iof
PINK,PC,(-) TPC,(-) CC AD, SCE, Soft ,nontender ,no mass.

KUB PRSTATE UTZ was requested which revealed : umremarkable

ultrasound study of bth kidney. urinary bladder and prstate gland.

Medication:

Levofloxacin 500mg/tab OD

Diet: DAT except dark colored foods

IVF: pnss 1l x 16 hrs
CPC PC MONITORING Q12

CASE DISCUSSION

INTRODUCTION:
Most rapidly spreading viral disease in the world (by who). The
four countries in the western pacific region Philippines, Cambodia,
Malaysia and Vietnam has the highest no of cases reported. Dengue
is all-year round in Philippines.

CLASSIFICATION OF DENGUE:
Denguewithoutwarningsigns
Denguewithwarningsigns
Severedengue

Dengue without warning signs

Lives or travels in dengue epidemic area with two or more
signs and symptoms off headache, body malaise, myalgia,
arthralgia,retroorbital pain, anorexia, nausea, vomiting, diarrhea,
flushed skin, rash. Lab test of at least CBC ( leukopenia with or
without thrombocytopenia and dengue NS1 antigen test or dengue
IGM antibody test optional. Confirmed dengue PCR or viral culture
isolation

Dengue with warning signs

Lives in or travels in dengue endemic area with two of the following
symptoms Abdominal pain or tenderness, Persistent vomiting,
Clinical signs of fluid accumulation, Mucosal bleeding, Lethargy;
restlessness, Liver enlargement, Laboratory: Increase in hematocrit
and/or decreasing platelet count.

Severe dengue
Lives in or travels to a dengue endemic area with fever of 2-7 days
and any of the above clinical manifestations for dengue with or
without warning signs, plus any of the following:
Severe plasma leakage, leading to:
Shock
Fluid accumulation with respiratory distress
Severe bleeding
Severe organ impairment
Liver: AST or ALT > or equal to 1000
CNS: e.g., seizures, impaired consciousness
Heart: e.g., myocarditis
Kidneys: e.g., renal failure

MANAGEMENT:
Patient who may be sent home (group A)
cantolerateadequatevolumesoforalfluids
Passurineatleastevery6hours
Donothaveanywarningsigns,particularlywhenfeversubsides.
Stablehematocrit

ACTION PLAN
Oral rehydration solution (ORS) should be given based on weight.
Reduce osmolarity of ORS containing sodium 45 to 60 mmol/ litre..
Sport drinks should not be given.

HOME CARE:
Adequate bed rest Adequate fluid intake(>5 glasses): milk, fruit
juice, isotonic electrolyte solution(ORS) and barley/rice water. Take
paracetamol (not more than 4 grms per day). Tepid sponging. Look
for mosquito breeding places around the home. Do not take NSAIDs,
e.g. acetylsalicylic acid (aspirin). Antibiotics are not necessary. If
warning signs for danger are observed ,take the patient immediately
to the nearest hospital.

Patient who are referred in for hospital management (group

B)
Warning signs: Co existing conditions like pregnancy, infancy,
oldage, DM, renal failure, chronic hemolytic diseases, etc. Social
circumstances like living alone, far from hospital.
Without warning signs: Encourage oral fluids or start intravenous
therapy. Isotonic solutions are appropriate for patients without
shock. Maintenance IVF is computed.
Dengue with warning signs: Obtain a reference hematocrit before
fluid therapy.
Give only isotonic solution such as 0.9% NaCl (saline), Ringers
Lactate, Hartmanns solution.
startwith57ml/kg/hrfor12hours,then
reduceto35ml/kg/hrfor24hours,and
reduceto23ml/kg/hrorlessaccordingtoclinicalresponse.
Reassess the clinical status and repeat the hematocrit.
If the hematocrit remains the same or rises only minimally,
continue with the same rate (2-3 ml/kg/hr) for another 2-4
hours.
If there is worsening vital signs and rapidly rising hematocrit,
increase the rate to 5-10 ml/kg/hr for 1-2 hours.
Reassess the clinical status, repeat hematocrit and review
fluid infusion rates accordingly.
Give the minimum intravenous fluid volume required to
maintain good perfusion and urine output of about 0.5
ml/kg/hr.
Intravenous fluids are usually needed for only 24 to 48 hours.

Patient who require emergency treatment