CLINICAL CASE

REPORT
[COMMUNICABLE DISEASE BLOCK]
Name: Mohammad Aimanazrul bin Zainudin
Matric number: 1228551
Academic Year: 2nd Year Phase II
PBL Group: Group 7
Clinical Tutor: Dr.
Declaration: I hereby declare that this case report is my own
original work and I will be responsible for this work.
Prepared by:
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Block and Patients Identification

Chief Complaints (CC)
History of Presenting Illness (HOPI)
Past Medical History
Past History
Family History
Socioeconomic History
Treatment/Drugs History
Review of Systems
Physical Examinations
General Examinations
Examination of Specific Systems
Problems List
Differential Diagnosis
Investigation
Final Diagnosis
Discussion
Treatment
Pathophysiology of Disease
Pathophysiology of Signs and Symptoms

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CONTENTS

1. Block and Patients Identification

Block: Communicable Disease Block
Patients Identification: 0692399

Name: Shivaji Patil

Age: 58y/o
Sex: Male
Race: Indian
Religion: Hindu
Occupation: Farmer
Marital Status: Married
Informer ; brother
Address: khanapur, Belagavi
Date of Admission: 22 September 2015
Date of Clerking: 24 September 2015

2. Chief Complaints
General Chief Complaints
1. Continous fever - 10 days, sudden onset
2. Generalized body ache 10 days

3. History of Presenting Illness and Past Medical History

History of Presenting Illness
The patient was apparently well since 10 days back when he
developed continuous fever that is sudden onset. The fever accompanies
with generalized body ache that is associated with chills and rigor
1. Continuous fever
a. Duration 10 days
b. Sudden in onset
c. Severity: mild

Complaint of sweating all the day

Not associated with vomiting
No abdominal pain
Accompanied with cough for 10 days; at night and morning
No sputum
Sometimes complaint of pulsatile headache

2. Past Medical History

The patient has no known history of Hypertension and non-diabetic. He had
not undergone any operations in the past or taken any significant drugs and
medications. Patient also do not have asthma, no history of TB and no recent blood
transfusion.
He had not been hospitalized in recent months and did not consult any other
doctors before the admission.

3. Past History
Family History
Similar complaints: Nil
Parents: Dead at old age
Children: not significant
Diseases: No family members with hereditary and infectious disease
such as diabetes, hypertension, and tuberculosis. No similar complaint
from the family
Causes of death in family: NIL
Socioeconomic History
Marital status: Married
Spouse (health and Job): healthy, housewife
Diet: Mixed
Alcohol consumption: Nil
Smoking: Nil
Drug abuse: Nil
Tobacco chewer since years
Treatment or Drugs History
Past and Present Drugs
Past: Nil
Allergic or Reaction to Drugs: Nil
History of surgery: Nil

4. Review of Systems
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GENERAL
1. WEIGHT LOSS: No
2. APPETITE: Reduced
3. THIRST: Nil
4. ENERGY/FATIGABILITY: Generalized weakness (+)
5. LUMPS: Lumps on left forearm
6. SLEEP: Normal
7. NIGHT SWEATS: nil
SYSTEMIC
GASTROINTESTINAL SYSTEM

RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM

REVIEWS
NO ABDOMINAL PAIN
NO VOMITING
NO FLATULANCE
NO HEARTBURN
NO INDIGESTION
NO DYSPHAGIA
NO DIARRHEA
NO CONSTIPATION
NORMAL STOOLS
NO ASSOCIATED PAIN
INCREASE BOWEL SOUND
ON AUSCULTATION
COUGH
NO HEMOPTYSIS
NOT ASSOCIATED WITH
CHEST PAIN
NO WHEEZING
Normal breathing
NO CHEST PAIN
NO PALPITATION
NO SYNCOPE
NO ANKLE OEDEMA
NO ORTHOPNEA
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GENITOURINARY SYSTEM

MUSCULOSKELETAL SYSTEM

CENTRAL NERVOUS SYSTEM

NO PND
NO HEADACHES
Heart Sounds Normal
NO DIFFICULTY IN PASSING
OUT URINE
NO URINE INCONTINENCE
NO HEMATURIA
NO NOCTURIA
NORMAL FREQUENCY
NO
POLYURIA
AND
OLIGOURIA

NO MUSCLE PAIN
NO JOINT STIFFNESS
NO SWELLING
NORMAL MOVEMENTS
WEAKNESS PRESENT

NO VISUAL PROBLEM
NO HEADACHE
NO FITS
NO FAINTING
NORMAL SENSATIONS

5. Physical Examination
1. General examination
The patient is lying comfortably in supine position supported with a
pillow. He was conscious, alert and well oriented to time and space. He was
not in pain neither in distress. His hydration status and nutritional status is
clinically adequate. There was no gross deformity any abnormal movement
or muscle wasting. There was IV line on back of right forearm.
Blood Pressure : 130/90 mmHg
Respiratory rate : 20 breath /m
Pulse rate : 66 bpm (Normal and regular)
Body temperature : afebrile
General Examination;
I.

II.

III.

Hands
moist and warm, dark complexion due to work and normal skin
colour
slight clubbing
no palmar erythema
no pallor (adequate capillary refill)
no thenar or hypothenar wasting
benign painless growth on right forearm, movable
unilateral fungal infection on right hand
Face
normal complexion
no pallor
conjunctiva was pinkish white
no discharge from orifices
oral hygiene was fairly good
tongue was moist and not coated
no cyanosis
no jaundice in sclera
no lymphadenopathy
Leg
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 Fungal infection on right nail (onychomycosis)

No pitting edema
CHEST & ABDOMENT: Normal Chest on auscultation (normal heart
sound) and abdomen increase bowel sound
2. Examination of Specific System (per-abdominal exam)
Inspection
SHAPE: Normal scaphoid
VISIBLE PERISTALSIS: Nil
ENGORGED VEIN: Not Present
UMBILICUS: Normal (inverted)
HERNIAL ORIFICE: No Hernial cases
DIVARICATION OF RECTI: Nil
SKIN OF ABDOMEN WALL: No spider Nevi, No Operation Scar,
No branding Mark, No pigmentation.
Palpation
SUPERFICIAL: Soft, tenderness at epigastric region of abdomen
DEEP: tenderness at epigastric, liver and Spleen not palpable
BIMANUAL PALPATION OF KIDNEY: Normal
BRUIT: Not heard
Percussion
FREE FLUID: Fluid thrill not noted
DULLNESS: Abdomen is mostly resonant on percussion
Auscultation
BOWEL SOUND: Heard Normal

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6. Problem list
Symptoms
1. Fever
2. Generalized body ache
3. Chills and rigor
Signs elicited
1. Tenderness at epigastric
2. Clubbing of nails
3. Onychomycosis

7. Differential diagnosis
1. Dengue fever
2. Malarial fever
3. Lymphatic filariasis

8. Investigations
1. Full blood count
2. Peripheral blood smear,
3. LFTs, RFT
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4.
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Blood Film for Malarial Parasite

Blood culture
Blood Serology test
Nail clipping for culture (onychomycosis )
Urine Microscopy, urine culture
1. Blood tests :
a) Full blood count :
- Hemoglobin level : to look for hemoglobin level.
- White blood cell count : if raise indicate infection
- Differential count : to indicate whether it is viral
( lymphocytosis ) or bacteria (neurophilia) infection
- Platelet count : to see platelet level, Thrombocytopenia and
haemoconcentration will occur in Dengue
- Peripheral blood film : to look for ant atypical lymphocytes
2. Serological tests :
a) Dengue serology : a rising antibody title will confirm dengue
fever
b) Widal test : if positive indicate typhoidc) Typhidot test : if
positive indicate typhoid
3. Microbiological test :
a) Blood culture and sensitivity : to detect any pathology organism
and resistance of antibody
b) Urine and stool culture : to detect any pathology organism
c) Tissue culture : to detect any virus

9. Final Diagnosis
DENGUE FEVER

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8. Discussion
1. Treatment of Patient
2. FLUID MANAGEMENT
Dengue with warning signs All patients with warning signs should
be considered for monitoring in hospitals
Obtain a baseline HCT before fluid therapy
Give crystalloids solution (such as 0.9% saline)
Start with 5 - 7 ml/kg/hour for 1-2 hours, then reduce to 3 - 5
ml/kg/hr for 2 - 4 hours, and
then reduce to 2 - 3 ml/kg/hr or less according to the clinical
response
If the clinical parameters are worsening and HCT is rising,
increase the rate of infusion
Non-shock patient
Encourage adequate oral intake

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 Intravenous fluids are indicated in patients who are vomiting,

unable to
tolerate oral fluids or an increasing HCT despite increasing oral
intake.
Crystalloid is the fluid of choice
Reassess the clinical status, repeat the HCT and review fluid
infusion rates accordingly

a. Medications
i. Paracetamol 500mg
ii. Antibiotics; ciprofloxacin

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3. Pathophysiology of disease
Mosquito bite

Inoculation of virus and reach to regional lymph nodes

Disseminated to reticuloendothelial system

Activation of reticuloendothelial system

Initial viraemia

Stimulate immune system

Release interferon and immunoglobin

Induce prostaglandin

Elevated temperature set point in

thermoregulatory center in hypothalamus

Heat production and conservation

Dengue fever

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4. Pathophysiology of signs and symptoms

1. Generalized body aches
Viremia

Viral multiply in macrophages and monocyte

Release interferon, interleukin, prostaglandin

Accumulates and cause generalized body inflammation

2. Headache
Dengue fever

Vasodilation of blood brain vessels

Increase cerebral blood flow

Increase intracranial pressure

Generalized headache

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