Internal Medicine I

MED35112
Clinical Case Write-Up (I)

Name : Nik Muhd Faris

SCM : SUKD1702080

Lecturer : Prof.Dr. Ma Han Ni

PATIENT’S IDENTIFICATION
RN : 18408
NAME : Ahmad Jelani
AGE : 42
GENDER : Male
RACE : Malay
MARTIAL STATUS : Not Married
OCCUPATION : Construction Worker ( housing)
DATE OF ADMISSION : 25/03/18
DATE OF CLERKING : 28/03/18
ADDRESS : Sibu
INFORMANT : Patient himself

Chief complain
Patient , a 42 years old malay gentleman with a known background of DM and Hypertension ,
presented with high grade fever for 4 days , associated with myalgia , arthralgia ,headache ,
abdominal pain and persistent vomiting .

History of Presenting Illness

Patient , apparently normal prior to admission . As for the fever , it was high grade , continuous
in nature and sudden of onset . it was associated with severe arthralgia and myalgia which
restricted his daily activities and even movement . At the same time , he complained of having
headache prominently over the right side of parietal region , face and eye . the headache was of
sudden onset , and lasted about hours . it was relieved by taking Paracetamol (PCM) and worsen
by direct light exposure .
As for the abdominal pain , it was got worsen periodically by days , located over the epigastric
region , radiating towards the left hypochondriac region . The pain was of tightness in nature
with a scale of 5 out of 10, relieved by laying supine , and worsen by leaning forward . he had 2
episodes of non projectile vomiting , prior to admission . it was yellow in colour with food
particle and there was no blood in the vomitus . this eventually leads to poor appetite and oral
intake .
Systemic review

Cardiovascular : No dyspnea , chest pain , palpitations , PND

Respiratory : No Dyspnea , light dullness on percussion over right side of chest ,
Gastrointestinal : Epigastric pain with vomiting
Central nervous : No confusion , syncope , fainting .
Genito urinary : no hematuria nor dysuria
Dermatology : Skin is slightly yellow , No rashes
Musculoskeletal : Athralgia and myalgia

Past medical history

In 2011, admitted to hospital due to Dengue and was discharged within a few days .
There was no previous history of surgeries nor blood transfusion .

Family history

He is second out of 7 siblings , and parents passed away due to old age with background of DM
and HTN . Theres no history of similar illness within family . Younger brother was diagnosed
having prostate enlargement and elder sister had hysterectomy 2 years ago while majority of the
siblings having DM .

Social history

He lives in a moderately occupied environment with his family at Mukah , does not smokes nor
drinks . He claimed to have DM and HTN for the past 5 years , compliant to medications and
regular blood glucose screening himself at home . Diet mainly consist of carbohydrates and
protein of meat source with no particular allergic to medications nor food . Strongly denied of
any usage of elicit drugs nor traditional medicine . He works as a construction worker at Sibu.
There was no recent travelling history , rafting nor swimming in river . There was recent
fogging in his area , about 2 weeks ago .

Summary
In summary , my patient is a 42 years old Malay gentleman admitted to Sibu Hospital with
complaint of high Fever for 4 days associated with myalgia , arthralgia , headache , abdominal
pain and vomiting .

Physical Examination

General Inspection .

On inspection , he was alert and conscious . he was laying on supine position supported by 1
pillow . There was no signs of gross deformities . cannula was attached on dorsal part of his right
hand . He was responsive and not in respiratory distress nor in pain . He appeared to be
nutritionally and hydrationally adequate .

Vital signs [taken 28/03/18]

Blood Pressure : 150/81

Temperature : 38.7
Respiratory rate : 82
Pulse Rate : 20
Pulse volume : normal
Pulse rhythm : regular
Weight : 63 Kg
Height : 165cm (informed my patient)
BMI : 23.14
General Examination

Hand :
The palm was warm , dry and pale
Capillary refill was normal
Skin was slightly yellowish
No signs of clubbing , koilonychia nor leukonychia
No signs of Infective Endocarditis
No signs of scars around the arm nor tenderness around the wrist
No signs of peripheral cyanosis .

Head and face

No yellowish discoloration of sclera

The conjunctiva was pale
The tongue looked dry and coated with no central cyanosis
Oral hygiene was satisfactory
No angular stomatitis
No tonsillitis
JVP was not raised
No lymphadenopathy
Chest

Skin was lightly yellowish

Chest expension was slightly reduced on right side
No surgical scars nor deformity
No rashes nor spider naevi seen
Axillary Lymph nodes were enlarged on right side

Lower Limb

Mild bilateral pedal oedema over the lower falls of the tibia
Nor deformities or surgical scars

Specific Examination ( Abdomen )

Inspection

The abdomen moves with every respiration

No abdominal distention
The navel was centrally located and was not inverted
No visible gross deformity of abdomen
No surgical scars
No dilatated vein or visible pulsations
No spider naevi , caput medusa nor gynaecomastea
Slight yellowish appearance of skin
Palpation

On Superficial palpation
No palpable mass
No tenderness

Deep palpation
No palpable mass found
Non tender abdomen

Liver palpation
Liver was enlarged , about 1 fingerbreadth below costal margin ,(13.5cm from liver dullness )

Spleen palpation
No enlargement of spleen

Percussion
Troube’s Space was resonant on percussion
No shifting dullness
Non ballotable kidneys

Auscultation
Bowel sound can be heard in all quadrants
No renal bruits heard
Provisional Diagnosis
Dengue
Positive Findings : High Grade Fever , persistant vomiting , headache , abdominal pain ,
myalgia,athralgia , Hepatomegaly , history of fogging .
Negative Findings : No rashes

Differential diagnosis
• Malaria
Positive Findings : Vomiting , High Grade Fever , abdominal pain , headache , organomegaly
Negative Findings : No chills and Rigors ,cough , no history of jungle tracking , (-) BFMP

• Typhoid Fever

Positive Findings : Fever , Vomiting , organomegaly

Negative Findings : No constipation nor diarrhea , no Rash (rose spots )

• Leptospirosis

Positive Findings : Vomiting , Headache , organomegaly , photophobia

Negative Findings : conjuctival suffusion , calf tenderness , diarrhea

Laboratory Findings (followed up from 25/03 – 28/03/18)

Vital Signs

Vital Signs / 25/03/18 26/03/18 27/03/18 28/03/18

 Date
BP(mmHG) 150/81 143/90 139/85 134/81
RR 22 22 23 21
PR 90 90 89 93
SpO2 (%) 99 98 95 97
Temp (C) 38.7 38 37.5 36.6

Arterial Blood Gas :

pH : 7.386 [7.35-7.45 ]
pO2 : 35.2mmHg [ 80-100 ]
pCO2 : 38.6 mmHg [ 35-45 ]
SO2© : 94.1 %

Haematological Findings
FBC
Date : 27/12/17

HGB : 13.6
PLT : 8x10^4
Urea :27
Creatine : 0.7
Sodium : 13.6
Potassium : 3.6

BFMP :
Negative

ELISA :
IgM IgG dengue positive

Treatment
Fluid Replacement Theraphy
Analgesics
Blood transfusion
Vital sign monitoring

Discussion

Dengue also known as Break bone disease , Philiphine , Thailand , Singapore Haemorhagic fever
, Dandy fever , And Onyang-Nyang Fever .
Dengue virus is an Arbovirus from the genus Flavivirus of family Flaviviridae , a single stranded
RNA with four types serotypes , (DEN 1 , 2 , 3,4 ) . Serotype 2 and 3 being most virulent among
the 4 types , and also common in Asia .
It is transmitted by Infected female Aedes Aegypti mosquito , and also less commonly by
A.Albopictus , polyneisienisis , Scutellaris Complex .

Mechanism and Pathophysiology

-Person bitten by Infected Mosquito
-Virus reaches the Regional lymph glands and dissemination into reticuloendothelial system
where it multiplies :
-Disseminated in Liver , multiplies in RES , causes HEPATOMEGALY
-Triggers immune response , release of cytokines from macrophages (IL-1 , TNF, IF-y) ,
-Stimulates anterior hypothalamus , (increase in PG synthesis ) , increase in thermoregulatory
setpoint , results in FEVER
-Increase in metabolic rate , increases tissue activity , and protein breakdown , causes lactic acid
accumulation , which results in MYALGIA
-Formation of antibody (antigen-antibody complex ) :
-Deposition in vascular endothelium :
-endothelia injury causes RASH

-vasodilation of blood vessel , causes increase in cerebral fluid flow and intercranial pressure
which results in HEADACHE
-Deposition in small capillaries in the eyes :
-triggers inflammatory response which results in RETRO-ORBITAL PAIN
-Deposition in the joint :
-triggers inflammatory response which results in ATHRALGIA

Investigation Analysis :
FBC :
To check for any increase in WBC and Decrease in platelets count
-Dengue virus replicates in WBC and platelets , thus destroying the cells and eventually causes
decrease in theWBC and platelet counts .

Hematocrit count :
To access the hydrational status of patient to prescribe IV fluids to prevent the patient in DSS

Liver Function Test :

To acess the degree of liver damage

Torniquet test :
To acess for heamorhagic fever

ELISA :
To check for antigen of causative agents in blood
NS1 antigen to confirm diagnosis of dengue
IgM suggest on going infection
IgG suggest any previous exposure

BFMP :
To rule out malaria .

Chest X-ray
To acess for any obvious pleural effusion or pericardial Effusion

ECG
In case of pericardial effusion , decrease in amplitude of all ECG waves suggest pericardial
effusion .

References :

• Masons Tropical Diseases

• Differential Diagnosis By Howard Fussell
• Mechanisms Of Clinical Signs