Vous êtes sur la page 1sur 15

CASE WRITE UP

PRIMARY CARE

ROTATION 4

NAME : MUHAMMAD AMIRUL HAFIZ BIN KHAIRUDIN

ID : 012013100122

SUPERVISOR : DR HAN

SUBMISSION DATE : 28 APRIL 2017


PATIENTS BIODATA

NAME NORELINAH BT ABD WAHID

AGE 44 YRS OLD

GENDER FEMALE
RELIGION ISLAM

ETHNICITY MALAY

ADDRESS JALAN TUN SAMBATHAN, TAMAN SRI ANDALAS, KLANG,


SELANGOR

MARITAL STATUS MARRIED

DATE OF BIRTH 19TH MARCH 1972

DATE OF CLERKING 21st APRIL 2017

CHIEF COMPLAINT
Mrs. Norelinah, a 44 year old woman from Klang come with chief complaint of fever and vomiting for 4
days
HISTORY OF PRESENT ILLNESS
Mrs. Norelinah with no underlying disease was apparently well untils he suddenly developed fever for 4
days. The fever was high grade fever, sudden in onset associated with chills and rigor, and intermittent in
nature. She took paracetamol that she bought in the pharmacy however it only temporarily relieved the
fever. Temperature was not recorded at home. The fever was associated with with vomiting and
generalized muscle and joint pain and reduced oral intake and reduced urine output.
Other than that, patient had vomited for 2 episodes per day for 4 days. The vomitus was small in amount
about 3 table spoon and she frequently vomiting after meal. So the vomitus contain mainly food particle
and It was a non-projectile and yellowish in colour. The vomitus contain no blood or mucus. She did not
take any medication at home for this symptom.
Besides that, patient did mentioned she had reduced oral intake for the last few days and also having
generalized body aches. She only managed to drink about one 1.5 litre bottle in a day. However, there is
no significant loss of weight noted. She also had reduced urine output which she normally urinates more
than 6 times a days but currently right now only 2 to 3 times a day.
She denied of having dengue warning signs such as abdominal pain, persistent vomiting, persistent
diarrhea, lethargy or bleeding tendency for example no gum bleeding or epistaxis.
The neighbourhood that she currently live in is a dengue prone area and fogging was done twice a week.
Th recent fogging was done a week ago from the day of clerking.
Otherwise, patient does not a history of jungle trekking, swimming in the waterfall or river or travelling
to malaria prone area . There is also no history of eating outside food and those who have similar illness
like her.
This is her 2nd time coming to Klinik Kesihatan Botanik, previous on her first visit yesterday, she was
asked to do a blood test and Combo test. Her platelet count is low and the Combo test showed that NS1
antigen was positive. She was asked by the doctor to drink more water, get enough rest and come again
the next following day.
Today, the day of clerking, blood test was done again and her platelet count is slightly increasing from
yesterday

PAST MEDICAL AND SURGERY HISTORY


Mrs. Noreliniah has no other known medical illnesses such as diabetes mellitus, malignancies or
deformities or neurological problems.
This is her first time diagnosed with dengue.
She does undergoes any surgery before
DRUG AND ALLERGY HISTORY
She has no drug history
There is no known allergy to food or medications.

FAMILY HISTORY

Kasi 7 space sini

Mr. Noreliniah is happily married and has 2 children. She has 4 siblings and both of his parents are still
alive. Her father is a known case of hypertension on medications.. Her children are all healthy. Otherwise,
beside her father, all her family member does not have chronic illness or malignancies.

SOCIAL HISTORY
Mrs. Noreliniah live in Taman Sri Andalas. She and her husband both are teachers. She and her
husband did not smokes and consumes alcohol. Her housing area is a dengue prone area
SYSTEMIC REVIEW
GENERAL No fatigue/lethargy/malaise
No loss of appetite

CARDIORESPIRAT No chest pain


ORY No shortness of breath or orthopnoea
No coughing
GASTROINTESTIN No abdominal pain
AL No indigestion
No altered bowel habits
No hematemesis or hemoptysis

GENITOURINARY No painful urination
No hematuria
PHYSICAL EXAMINATION
Under supervision by Doctor Liyana.
GENERAL EXAMINATION
Patient is middle aged woman lying comfortable in supine position. She was conscious and alert
of surroundings. Patient seemed well hydrated and was cooperative. She is not under respiratory distress
or pain
VITAL SIGNS

VITAL SIGNS READINGS

TEMPERATURE 37.2 degree Celsius


(afebrile)

PULSE RATE 68bpm


(regular rhythm, good volume)

BLOOD PRESSURE 120/60mmHg

RESPIRATORY RATE 17 /min

Weight :
Height :
BMI :
GENERAL INSPECTION AND EXAMINATION
PARTS FINDINGS
Hands Warm and pink hands
No tobacco stainning of nails
No cyanosis present
No pallor of palms
Capillary refile time is less than 2 seconds

Eyes The conjunctiva was not pale


No yellowish discoloration of the sclera
Mouth Lips were normal
Tongue has yellowish coating due to dehydration
Gums and buccal mucosa were normal
No cyanosis of the tongue
Leg Theres no pitting edema

ABDOMINAL EXAMINATION

Inspection:

Abdomen was flat and not distended. The flank was not full.
Umbilicus was centrally located and inverted
All nine quadrants moves symmetrically with respiration.
There is no visible mass, dilated vein and surgical scars can be seen.

Palpation:

Abdomen was soft and non- tender.


No abdominal masses were felt during superficial and deep palpation.
Kidney was not ballotable.
Liver and spleen were not palpable.

Percussion

Resonant (tympanic) on all 9 quadrant


No shifting dullness and no fluid thrills

Auscultation

Normal bowel sound was heard


RESPIRATORY SYSTEM

Inspection :

The chest move bilaterally symmetrical for every respiration


She is not under respiratory distress and no usage of accessory muscle
There was no surgical scar, no dilated veins, no visible pulsation
No deformity seen on chest
Respiratory rate is 17 breaths per min

Palpation :

Trachea is not deviated and is centrally located


Vocal fremitus is equal and bilaterally heard at all three zones
Chest expansion is bilaterally equal and symmetrical.

Percussion :

Resonant sound was heard bilaterally at all sites of percussion.

Auscultation :

Air entry is equal and bilateral on both lungs


Vesicular breath sound heard with normal intensity
No added sound heard

CARDIOVASCULAR SYSTEM

Inspection :

No chest deformity, no visible pulsation and no surgical scar


There was no precordial bulging and no dilated veins.

Palpation :

Apex beat felt at 5th intercostals space, at midclavicular line


No parasternal heaves or palpable thrills felt

Auscultation :

1st and 2nd heart sound heard at all 4 areas.


Normal heart sound and no murmur or thrills heard.
No other additional sounds heard.
SUMMARY
Mr. Noreliniah 44 years old women with no known medical illness came in to the Klinik
Kesihatan Botanik with chief complain of fever and vomiting for 4 days. The fever was high grade
and associate with chills and rigor. The vomiting is non projectile for 2 episode per day. It was
associated with generalized muscle and joint pain, reduced oral intake and reduced urine output

Upon examination, there is no abnormal findings.


PROVISIONAL DIAGNOSIS
Dengue fever, day 4 of illness without warning sign
Points Supporting Diagnosis
High grade fever
Vomitting
Generalized muscle and joint pain
Reduced urine output
Reduce oral intake
Living in dengue prone area

DIFFERENTIAL DIAGNOSIS

DIAGNOSIS REASONS SUPPORTING REASONS AGAINST


Leptospirosis Fever No history of recent
travelling
Diarrhea
No jaundice
Myalgia

Malaria Fever No travel history to


endemic areas
No characteristic
intermittent chills and
rigors with sweating

INVESTIGATIONS

Full Blood Count

20th April 2017


Results Normal ranges

White blood cell 2.0 x 103/ L 4.5-13.5 x 103/ L

Red blood cell 5.09 x 106 / L 3.9-5.6 x 106 / L

Haemoglobin 12.7 g/dL 11.5-14.5g/dL

Hematocrit 40.41% 37-45%

Mean cell volume 79.5fl 76-96fl

Mean cell 26.7pg 27-31pg

haemoglobin

Platelet 111 x 103 / L 150-400 x 103 / L


21hb April 2017

Results Normal ranges

White blood cell 3.9. x 103/ L 4.5-13.5 x 103/ L

Red blood cell 4.69 x 106 / L 3.9-5.6 x 106 / L

Haemoglobin 11.9 g/dL 11.5-14.5g/dL

Hematocrit 37.8% 37-45%

Mean cell volume 80.6fl 76-96fl

Mean cell 25.4pg 27-31pg

haemoglobin

Platelet 168 x 103 / L 150-400 x 103 / L

Interpretation :

White blood cell result on 20th April is low and it is getting increasing based on the latest
result which is on 21st April

The platelet is increasing from 111 x 103 / L to 168 x 103 / L .The target platelet for
this patient is 200 x 103 / L

Hematocrit is stable
Rapid Combo Test
Dengue NS1 antigen: Positive
Antibody IgG: Negative
Antibody IgM Negative

Interpretation :
NS1 is useful for early dengue marker. NS1 positive indicate it is a acute dengue infection
IgM is negative. So, a repeat sample must be taken in recovery phase

MANAGEMENT
Non pharmacological:

Adequate bed rest


Encourage the patient to drink more plenty of fluid (more than 8 glassess or 2 litres)
Tepid sponging
Advise patient to use mosquito repellent or rest under mosquito net
Advise patient and her family to look for mosquito breeding places in and around the
home and eliminate them
Tell patient if there is any warning signs, immediately come to the hospital.

Pharmacological:

- Tablet PCM 500mg 4 times daily

In addition:

Notification of the disease within 24 hours by the attending doctor


Parents were told to come back again the next following day for repeating blood test.
Parents were also provided with outpatient dengue monitoring record
DISCUSSION

In this patient, first of all we need to have a several ideas and diagnosis regarding fever. Fever itself is a
huge topic and a proper approach and examination should be done. This patient Mrs. Norelinah had a 4
days fever and diarrhea.

She is high likely to have a dengue infection by evidence of positive NS1 antigen in Rapid Combo Test
and Low platelet count in blood test. What we worry the most regarding dengue are plasma leakage,
bleeding and organ impairment. In these case, a proper monitoring and management should be carried
out.

Just recently last 3 weeks ago on 7th April 2017, the Health Ministry has approved the dengue vaccine to
be used in Malaysia. This is a great news for Malaysia as dengue fever has a potential to be a life
threatening illness.

The vaccine gives an overall average of 66% protection against dengue infection, 93% against severe
dengue and 80% against hospitalisation for dengue, for those aged between nine and 16.

Dengue fever is a vector-borne disease caused by infection of Dengue virus transmitted by female
mosquito Aedes aegypti and Aedes albopictus

Classification:

1. Dengue (with warning sign and no warning sign)

2. Severe dengue (severe shock +/-: respiratory distress, severe hemorrhage and organ failure)

Incubation period: 4-10 days

Phases: Febrile phase, Critical phase and Recovery phase


A few condition is require to suspect someone having a dengue fever :
Fever and at least TWO of the following:
Nausea and vomitting
Aches and pain
Rashes
Live in dengue prone area
Leukopenia
Any warning sign
Positive dengue lab test

Based on examination, Mrs.Norelinah does not show any abnormal finding that can suggest that she in a
severe condition. Mrs. Norelinah seems improving based on increasing platelet count. However we need
to monitor her condition for any warning signs such as :

Mrs. Norelinah need to be on daily follow up until her platelet count reach the targeted value which is 200
and her symptoms improved.
The patient with need to always update her Dengue Monitoring Record.