PATIENT DETAILS

NAME: Mr Abdul Hadi bin Mahmood

R/N: HRPZ429758

D.O.B: 09/07/1955

AGE: 59 years old

SEX: Male
OCCUPATIONAL:

ETHNIC GROUP: Malay

MARITIAL STATUS: Married

DATE OF ADMISSION: 07/04/2015

WARD: Bendahara

DATE OF DISCHARGE: 12/04/2015

INFORMANT: Patient

CHIEF COMPLAINT
The patient Abdul Hadi bin Mahmood, a 59 year-old male Malay was presented to
HRPZ II with the complaint of Fever associated with sore throat, joints pain and vomiting
5 days prior to admission.
HISTORY OF PRESENTING COMPLAINT
He was apparently well until 5 days ago when the fever developed. Regarding the
fever, it was of sudden onset and continuous in nature. It also associated with sore throat,
sweating and joint pain. He went sought general practitioner for treatment and was given
antibiotics for both fever and sore throat. The fever was apparent at night and early
morning, not aggravated but relieved by taking Panadol.
For the sore throat, it developed simultaneously with the fever. The general
practitioner said his left tonsil was swollen so he was given antibiotic to overcome the
swelling. He claimed to experience pain during oral intake.
Regarding the vomiting, its onset was abruptly around 2 days prior to admission.
There was no nausea but the vomiting was associated with loss of appetite (LOA) and
poor oral intake. In the first episode, the vomitus contained food material and was
yellowish in color. He denied any presence of blood in the vomitus. For the subsequent
bouts of vomiting, it was whitish and scanty in volume. The frequency of vomiting
reported was twice per day.
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He also stated he had a mild epigastric pain which radiated to the left
hypochondriac region. He gave the pain score of 3 out of 10 and claimed it was due to
poor oral intake, loss of appetite and the vomiting bouts.
Otherwise there is no history of recent travelling to other tropical or endemic
areas. No fogging was done in his neighborhood in the past 2 months and patient was
unsure of any dengue cases occurrence in his neighborhood recently.
SYSTEMIC REVIEW
CNS

: fever, headache no loss of consciousness, no blurred vision

CVS

: no chest pain, no palpitation, no leg swelling, no orthopnea, no PND

RESP : no cough, no hemoptysis, no shortness of breath, no nasal bleeding

GIT

: vomiting, loss of appetite, no altered bowel habit, no loss of weight

GUT : no frequency, no dysuria, no haematuria

MSK : joint pain, slight yellowish discoloration, no joint swelling, no muscle pain, no
muscle cramp, no bleeding tendency
PAST MEDICAL / SURGICAL HISTORY
In 2007, he was admitted to the hospital for liver biopsy due to marked ascites and
abdominal pain. He was diagnosed to have autoimmune hepatitis. There is no history of
blood transfusion and any other co-morbidity.
DRUG HISTORY & ALLERGIES
He was on:
-

Paracetamol

Phenoxymethylpenicilin 250mg

There is no known allergy to foods and medications

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FAMILY HISTORY
Mr. AH is the eldest out of 2 siblings. All of his siblings are healthy. He is married
with 5 children with the eldest being 34 years old and youngest being 17 years old. All of
his children and including his wife are well and healthy.
SOCIAL & ENVIRONMENTAL
Mr. AH lives at Taman Sri Bahari, 15200 Kota Bharu with his wife and children
in a single storey terrace house with proper water and electrical supply. He is non smoker
and does not consume any alcohol.

PHYSICAL EXAMINATION
GENERAL INSPECTION
On inspection, he was alert and conscious. He was lying comfortably in supine
and flat position supported by 1 pillow. There were no signs of gross deformity. There
was a canula attached on the dorsum of his right hand. He was not in respiratory distress
or in pain. He was nutritionally and hydrationally adequate.

Vital Signs
Blood Pressure

: 121/54 mmHg

Temperature

: 37.5 oC

Respiratory Rate

: 23 breath/min

Pulse rate

: 68 beat/min

Pulse volume

: Adequate

Pulse rhythm

: Regular

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General Examination

Hand
The palm was warm, dry and pale.
Capillary refill were normal.
Skin was slightly yellowish.
No signs of clubbing.
No peripheral cyanosis.
No signs of koilonychias or leukonychia.
No significant signs of tenderness around her wrist.
No present of scars around the arm.

Head and Face

Presence of yellow discoloration of sclera.
The conjunctiva was pale.
The tongue looked dry and coated.
No central cyanosis.
Oral hygiene was satisfactory.
No angular stomatitis.

Chest
The skin was normal in color.
Chest expansion equal on both sides.
No chest deformity.
No surgical scar.
No presence of spider naevi.
No rashes.

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Lower limbs
Both dorsalis pedis and posterior tibialis pulses were palpable.
Absent of ankle oedema or other deformity.

Lymph Nodes
All lymph nodes were normal, no enlargement.

Specific Examination (Abdominal)

Inspection
The abdomen moves with every respiration.
The navel was centrally located and was not inverted.
Present of laparoscopy scars due to the liver biopsy done previously.
No abdominal distention.
No gross deformity present.
No dilatable vein or visible pulsation.
Palpation
-

On superficial palpation
No palpable mass.
No tenderness.

On deep palpation
The abdomen was non-tender.

Liver palpation
There is slight enlargement of liver around 2 finger breadth below the costal line.
No tenderness.

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Spleen palpation
No enlargement of spleen.
Surface was smooth with rounded lower border.
The upper border could be reached.
The spleen was non-tender.

Percussion
Troubes space percussion was resonance.
No shifting dullness or fluid thrills.
No ballotable kidneys.
Auscultation
Bowel sounds could be heard on all quadrants.
No renal bruits.

CLINICAL SUMMARY
Mr. AH is a 59 years-old Malay male with the history of autoimmune hepatitis
was admitted to HRPZ II with the complaint of low grade fever associated with sore
throat, joints pain, sweating and vomiting 5 days prior to admission.

PROVISIONAL DIAGNOSIS
Based from the history and physical examination, my provisional diagnosis is
dengue fever. This is because; from the history itself there was fever, headache,
persistent vomiting, joint pain, and abdominal pain present. Whereas on examination,
there were positive signs for jaundice and hepatomegaly as well.

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DIFFERENTIAL DIAGNOSIS
Although the history and physical examination was very suggestive of dengue
fever as mentioned above, I would like to consider other differential diagnosis as follow:
No DDx
1

Malaria

Positive findings
Headache

Negative findings
Flu like illness

Vomiting

Myalgia

Jaundice

Diarrhoea

Fever

Cough

Chikungunya

Fever
Joint pain

Typhoid fever

High grade fever

Headache
Abdominal pain

Rashes
Conjunctivitis
Petechiae
Photophobia
Stiffness of joints
Dry cough
Diarrhoea
Constipation

FINAL DIAGNOSIS
Dengue Fever
INVESTIGATIONS
Several investigations need to be done in order to confirm the diagnosis and to assess the
severity, as well as to assess the general condition of this patient.
Full Blood Count
-

To check for any increase in white blood cells or decrease in platelet levels.
Relevance: the dengue virus replicates in white blood cells and platelets hence
destroy the cells during the process. Resulting in low white blood cells and
platelets.

Hematocrit count
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To assess the hydrational status of the patient in order to prescribe IV fluid to

prevent the dengue shock syndrome.

Liver Function Test (LFT)

-

To assess the degree of liver damage/involvement.

Tourniquet test
-

To rule out dengue.

ELISA (Enzyme Linked Immuno Sorbent Assay)

-

To check for antigen of the causative agent in blood.

NS1 antigen, to confirm diagnosis of dengue.
IgG and IgM also can be presented.

Blood smear
-

To rule out malaria

Relevance: under microscope, the slide will show organism in the red blood cell

DISCUSSION
Dengue is one of the most important arthropod-borne viral diseases in terms of
human morbidity and mortality. Dengue has become an important public health problem.
It affects tropical and subtropical regions around the world, predominantly in urban and
semi urban areas.
Dengue infection is caused by dengue virus which is a mosquito-borne flavivirus.
It is transmitted by Aedes aegypti and Aedes albopictus. There are four distinct serotypes,
DEN-1, 2, 3 and 4. Each episode of infection induces a life-long protective immunity to
the homologous serotype but confers only partial and transient protection against
subsequent infection by the other three serotypes. Secondary infection is a major risk
factor for DHF due to antibody-dependent enhancement. Other important contributing
factors for DHF are viral virulence, host genetic background, T-cell activation, viral load
and auto-antibodies.
The incubation period for dengue infection is 4-7 days (range 3-14). It may be
asymptomatic or may result in a spectrum of illness ranging from undifferentiated mild
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febrile illness to severe disease, with or without plasma leakage and organ impairment.
Symptomatic dengue infection is a systemic and dynamic disease with clinical,
hematological and serological profiles changing from day to day. These changes
accelerate by the hour or even minutes during the critical phase, particularly in those with
plasma leakage. Understanding the systemic and dynamic nature of dengue disease as
well as its pathophysiological changes during each phase of the disease will produce a
rational approach in the management of dengue.
CLINICAL COURSE OF DENGUE INFECTION
Dengue infection is a dynamic disease. Its clinical course changes as the disease
progresses. After the incubation period, the illness begins abruptly and will be followed
by 3 phases: febrile, critical and recovery phase.
i.

Febrile Phase
Typically, patients develop high grade fever suddenly. This acute febrile phase

usually lasts 2-7 days and often accompanied by facial flushing, skin erythema,
generalized body ache, myalgia, arthralgia and headache. Some patients may have sore
throat, injected pharynx and conjunctival injection. Anorexia, nausea and vomiting are
common. These clinical features are indistinguishable between DF and DHF. Mild
hemorrhagic manifestations like positive tourniquet test or petechiae and mucosal
membrane bleeding may be seen in DF and DHF. Per vaginal bleeding is common among
young adult females. Massive vaginal bleeding and gastrointestinal bleeding may occur
during this phase but are not common. The findings of an enlarged and tender liver are
more suggestive of DHF. The earliest abnormality in the full blood count is a progressive
decrease in total white cell count. This should alert the physician to a high index of
suspicion of dengue especially when there is positive history of neighborhood dengue.
This disease should be notified as early as possible to prevent disease from assuming
epidemic proportion.
ii.

Critical Phase

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The critical phase occurs towards the late febrile phase (often after 3rd day of
fever) or around defervescence (usually between 3rd to 5th day of illness but may go up
to 7th day) when a rapid drop in temperature may coincide with an increase in capillary
permeability in some patients. In other viral infections, the patients condition improves
as the temperature subsides, but the contrary happens in DHF. At this point the patient
will either become better if no or minimal plasma leak occurs, or worse if a critical
volume of plasma is lost. The critical phase lasts about 24 - 48 hours. Varying circulatory
disturbances can develop. In less severe cases, these changes are minimal and transient.
Many of these patients recover spontaneously, or after a short period of fluid or
electrolyte therapy. In more severe forms of plasma leakage, the patients may sweat,
become restless, have cool extremities and prolonged capillary refill time. The pulse rate
increases, diastolic blood pressure increases and the pulse pressure narrows. Abdominal
pain, persistent vomiting, restlessness, altered conscious level, clinical fluid
accumulation, mucosal bleed or tender enlarged liver are the clinical warning signs of
severe dengue or high possibility of rapid progression to shock. The patient can progress
rapidly to profound shock and death if prompt fluid resuscitation is not instituted. It is
important to note that thrombocytopenia and haemoconcentration (evidenced by a raised
haemotocrit (HCT) from baseline or a drop in HCT after rehydration) are usually
detectable before the subsidence of fever and the onset of shock. The HCT level
correlates well with plasma volume loss and disease severity. However, the levels of HCT
may be equivocal when there is frank haemorrhage, early and excessive fluid
replacement or untimely HCT determinations. Leucopaenia with relative lymphocytosis,
clotting abnormalities, elevation of transminases [typically the level of aspartate
aminotransaminase (AST) is about 2-3 times the level of alanine aminotransaminase
(ALT)], hypoproteinaemia and hypoalbuminaemia are usually observed.

iii.

Recovery Phase

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After 24 - 48 hours of defervescence, plasma leakage stops and is followed by

reabsorption of extravascular fluid. Patients general well being improves, appetite
returns, gastrointestinal symptoms abate, hemodynamic status stabilizes and diuresis
ensues. Some patients may have a classical rash of isles of white in the sea of red. Some
may experience generalized pruritus. Bradycardia and electrocardiographic changes are
not uncommon during this stage. It is important to note that during this phase, HCT level
stabilizes or drops further due to haemodilution following reabsorption of extravascular
fluid. The recovery of platelet count is typically preceded by recovery of white cell count.
Management
-

Mainly supportive care for the patient.

Fluid replacement therapy (fluid and electrolyte) to prevent severe dehydration
associated with dengue.
Pain killers such as aspirin to alleviate the symptoms.
Blood transfusion, to replace blood loss and improve platelet count.
Monitor vital signs such as blood pressure.

Complication
- If severe, dengue fever can damage the lungs, liver or heart. Blood pressure can
drop to dangerous levels, causing shock and, in some cases, death.
Prevention
-

Stay in air-conditioned or well-screened housing. It's particularly important to

keep mosquitoes out at night.
Reschedule outdoor activities. Avoid being outdoors at dawn, dusk and early
evening, when more mosquitoes are out.
Wear protective clothing. When you go into mosquito-infested areas, wear a
long-sleeved shirt, long pants, socks and shoes.
Use mosquito repellent. Such as mosquito spray.
Reduce mosquito habitat. The mosquitoes that carry the dengue virus typically
live in and around houses, breeding in standing water that can collect in such
things as used automobile tires. Reduce the breeding habitat to lower mosquito
populations.

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