Clinical Case Write Up Sample

1. CLINICAL CASE WRITE-UP
COMMUNICABLE DISEASE BLOCK



NAME : UMI NADHIRAH AISYAH MOHD ROKHIBI
MATRIC NO. : 107550
I/C NO. : 900626-02-5634
YEAR : 3
TUTOR : DR. MOHAMMAD ZIKRI AHMAD

2. PATIENT’S IDENTIFICATION
R/N :
Name : NurFatenSyuhadabinti Muhammad
Age : 19 years old
Address : KubangKerian, Kelantan.
Gender : Female
Race : Malay
Marital status : Single
Occupation : Student
Date of Admission : 7/11/2012
Date of Clerking : 7/11/2012
Informant : Patient herself

CHIEF COMPLAINT
The patient NurFatenSyuhada Muhammad, a 19 year-old female Malay was presented to
HUSM with the complaint of fever associated with sore throat, joints pain and vomiting 5
days prior to admission(PTA).
HISTORY OF PRESENTING ILLNESS
She 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. She went to the 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 her left tonsil was swollen so that she was given antibiotic to overcome the
swelling. She 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
colour. She 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.
She also stated she had a mild epigastric pain which radiates to the left hypochondriac
region. She gave the pain score of 2 out of 10 and claimed it was due to poor oral intake, loss
of appetite and the vomiting bouts.

3. SYSTEMIC REVIEW
System Sign & Symptom Findings
Genitourinary Dysuria No

Hematuria

No
Dermatology Discolouration Slightly yellowish
Rashes No
Respiratory Shortness of Breath No
Cough No
Sore throat Yes
Nasal bleeding

No
Cardiovascular Chest pain No
Gastrointestinal Nausea

No
Vomiting

Yes
Musculoskeletal
Joint pain
Yes, especially in lower
limbs
Muscle pain No
Central Nervous Blurring of vision No
Photophobia No
Drowsiness No

4. PAST MEDICAL AND SURGICAL HISTORY
In 2007, she was admitted to the hospital for liver biopsy due to marked ascites and
abdominal pain. She was diagnosed to have autoimmune hepatitis.
There is no history of blood transfusion and any other comorbidity.
FAMILY HISTORY
She is the youngest out of two siblings. There is no similar history of the same illness in the
family.
SOCIAL HISTORY
Currently she is a student at a local college and lives in KubangKerian which is an endemic
area. She denied any recent contact with tuberculosis patient and also a non-smoker.
DIET HISTORY
She had poor oral intake and loss of appetite. She denied any food allergies.
DRUG HISTORY
She denied of any drug allergies.
SEXUAL HISTORY
She denied any sexual intercourse or abuse.
TRAVEL HISTORY
She had no recent travel history to other tropical and endemic areas.
SUMMARY
This patient is 19 years-old female student with the history of autoimmune hepatitis was
admitted to HUSM with the complaint of low grade fever associated with sore throat, joints
pain, sweating and vomiting 5 days prior to admission.

5. PHYSICAL EXAMINATION
General Inspection
On inspection, she was alert and conscious. She 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 her right hand. She was not in respiratory distress or in
pain. She was nutritionally and hydrationally adequate.


Vital Signs
Blood Pressure : 121/54 mmHg
Temperature : 37.5 degrees Celcius
Respiratory Rate : 16 breath/min
Pulse rate : 56 beat/min
Pulse volume : Adequate
Pulse rhythm : Regular


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
Present 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.

6. Chest
The skin was normal in colour.
Chest expansion equal on both sides.
The lung is cleared.
No chest deformity.
No surgical scar.
No presence of spider naevi.
No rashes.

Lower limbs
Bothdorsalispedis 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.

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

7. Percussion
Troube’s 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.

DIFFERENTIAL DIAGNOSIS
No DDx Positive findings Negative findings
1 Dengue fever Fever
Headache
Persistent vomiting
Abdominal pain
Jaundice
Joint pain
Hepatomegaly
Rashes
2 Malaria Headache
Vomiting
Jaundice
Fever
Flu like illness
Myalgia
Diarrhoea
Cough
Rashes
3 Chikungunya Fever
Joint pain


Conjuctivitis
Petechiae
Photophobia
Stiffness of joints
4 Typhoid fever High grade fever
Headache
Abdominal pain
Dry cough
Diarrhea
Constipation

PROVISIONAL DIAGNOSIS
Dengue fever.

8. DISCUSSION
PATHOPHYSIOLOGY
Person was bitten by female Aedesaegyptimosquitos
(inoculation) then virus reaches the regional lymph glands
The virus disseminated into the reticuloendothelial system (multiply)
Trigger immune response











Release of cytokines
from macrophages
(IL-1,TNF,IF-γ)
Formation of antibody
(antigen-antibody complex
formed)
Stimulate anterior
hypothalamus
(↑PG synthesis)
↑ thermo-regulatory
set point
fever
↑↑ metabolic rate
↑↑ tissue activity &
protein breakdown
(accumulate)
Lactic acid
accumulation

Muscle pain
(myalgia)

Deposit in the joint
Trigger inflammatory
response
Joint pain (arthralgia)
Deposit in
vascular
endothelium
Endothelial injury
Rash
Vasodilation of blood
vessels
↑ cerebral fluid flow
↑ intracranial pressure
headache
Deposit in small
capillaries in eyes
Trigger inflammatory
response
Retro orbital pain
Disseminated in liver
and spleen
Multiply in RES Hepatomegaly

9. INVESTIGATIONS

Full Blood Count
- To check for any increase in white blood cells or decrease in platelet levels.
- Relevant : the dengue virus replicates in white blood cells and platelets hence destroy
the cells during the process. Results in low wbc and platelets.

Hematocrit count
- 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.
- NS1antigen,to confirm diagnosis of dengue.
- IgG and IgM also can be presented.

Blood smear
- To rule out malaria
- Under microscope, the slide will show organism in the red blood cell

10. 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.