St.

Lukes Medical Center

TALOSIG
34

Department of Medicine

Residents Manage Case

160113414 Ward/Room No
4
ANNEX 2 2412
Attending Physician
Resident
Dr. Nestor Santiago
Ferron F. Ocampo, MD
MICHAEL

SALIENT FEATURES:
Subjective:
CC: Fever
Patient is a 34/Male, non-hypertensive, nondiabetic, who sought consult due to fever. History
started 4 days prior to admission, when the patient
developed undocumented fever, without associated
symptoms such as cough, colds, vomiting,
abdominal pain, loose stools, or dysuria. Patient
took Paracetamol which provided temporary relief of
fever. Interim, there was persistence of intermittent
febrile episodes. One day PTA, patient still had fever
with associated body malaise and decreased
appetite. Patient sought consult at SLMC-ER, where
CBC was done, which showed WBC=4770 and
platelet=159k, and positive Dengue NS1 test.
Patient was discharged and advised follow-up and
serial CBC tests. Few hours PTA, patient still had
intermittent fever and generalized body weakness.
CBC revealed a WBC count of 3620 and platelet
count of 131K. Patient sought consult and was
advised admission.

Date Admitted
January 5, 2016
Date Discharged
January 10, 2015

Objective:
Conscious, coherent, not in cardiorespiratory
distress
BP 120/80 HR 95 RR 21 T 37.6C
Skin warm with good turgor. No active skin
dermatoses. No pruritus, spider angiomata,
telangiectasias
Normocephalic, atraumatic skull. No active lesions
on scalp.
Anicteric sclerae, pink palpebral conjunctivae
No tragal tenderness. Non-erythematous
tonsillopharyngeal walls.
Slightly dry lips, moist tongue
Nondistended neck veins. No cervical
lymphadenopathies
No pigeon chest, no kyphoscoliosis. Symmetric
chest expansion, Clear breath sounds.
Adynamic precordium, normal rate, regular rhythm.
Distinct heart sounds. No murmur. No S3 gallop
Flat abdomen, non-distended, normoactive bowel
sounds, soft, nontender.
Full and equal pulses, no edema

Review of Systems:
General: No weight loss.
HEENT: No tinnitus, hoarseness. No dysphagia,
Respiratory: No orthopnea and PND. No hemoptysis
Cardiovascular: No palpitations. No chest pain.
Gastrointestinal:
No
loose
stools,
melena,
hematochezia, anorexia
Genitourinary: No urgency, gross hematuria,
frequency, flank pains
Endocrine: No heat and cold intolerance, polyuria,
polydipsia, polyphagia
Hematopoietic: No easy bruisability, spontaneous
bleeding, pallor
Neurologic: No seizures, weakness, numbness,
change in behavior
PMHx: No hypertension and DM Type 2; no known
allergies; no previous surgeries/hospitalizations
FHx: no Hypertension, DM, Bronchial Asthma,
Cancer
PSHx: Non-smoker, Non drinker of alcoholic
beverages
ADMITTING IMPRESSION:
Dengue Fever without Warning Signs
DIAGNOSTIC / THERAPEUTIC PLANS:
Diagnostics:
CBC
Therapeutics:
Plain NSS 1L x140ml/hr, Paracetamol 500mg/tab, 1 tablet for T >37.8C
1

St. Lukes Medical Center

Department of Medicine

Residents Manage Case

BRIEF COURSE IN THE WARD

Patient was admitted and was managed as a case of Dengue fever without warning signs. He was hydrated
with PNSS 1L X 140 ml/hr and serial CBC monitoring was done. During the course of his illness, patient
continuously had febrile episodes (Trange 38.0 39.0C) and was given Paracetamol for fever control. He did
not have any bleeding episodes, abdominal pain, severe headache and bloody stools or urine. Serial CBC
consistently showed leukopenia with decreasing trend of platelet (as low as 37,000). On the 4 th hospital
day, patient became afebrile and CBC showed increasing platelet count. On the 5 th hospital day, patient
denied any subjective complaints. Vital signs remained stable, and CBC showed increasing trend of platelet
count; hence, patient was discharged improved.
FINAL DIAGNOSIS:
Dengue Fever without Warning Signs
CONDITION ON DISCHARGE:
Improved
FOLLOW-UP/AFTER CARE INSTRUCTIONS:
Follow-up after 1 week with HMO
Prepared by:

Verified by:

FERRON F. OCAMPO, MD
IM (Neurology) Resident

NESTOR L. SANTIAGO, MD
Consultant-In-Charge / Attending Physician