DAVAO DOCTORS HOSPITAL

Davao City
DEPARTMENT OF INTERNAL MEDICINE

DEFINED DATA BASE

Hospital Reg No: DDH Room/Bed No.: 1 Ward: Female ward

Date/Time Admitted:01/13/2020;3pm Date/Time Interviewed: 01/15/2020; 4pm
Informant: Patient Reliability: 85%

GENERAL DATA:
Patient Name: L. L.
Sex: Female
Age: 18 years old
Marital Status: Single
Occupation: Student
Religion: Roman Catholic
Address: Bankerohan, Davao City

CHIEF COMPLAINT:
Fever and Headache

HISTORY OF PRESENT ILLNESS

4 days prior to admission, patient claimed to have fever and headache. Fever was noted to be
38˚C that occurs during the day and intermittent in timing. She took paracetamo(500mg) three times a
day to ease the symptom but no relief. She described the headache as persistent, biparietal and
characterized as pounding with a pain scale of 10/10. Patient consulted the school physician and
urinalysis was done which reveals bacteuria thus the diagnosis of urinary tract infection. She was
given cefuroxime 500mg.
Hours before admission, patient symptoms persist with fever documented as 38˚C hence,
prompted her to seek further evaluation.

PAST MEDICAL HISTORY

The patient had no history of any childhood illnesses and any psychiatric illnesses. No history
of hospitalizations and past surgery. She reports to have complete immunization from the local health
center.
Medication
Cefuroxime 500mg BID
Allegies
She has no known allergies to foods and medications.
Diet
She is taking average Filipino diet thrice a day.
Immunizations
Immunization is complete and was taken in the health center according to the patient's
mother. Recently vaccinated for hepatitis B for school entrance and have reactive anti-HBS titers.
OB History
Menarche age 13. Last menses was Jan 12, 2020. Menstrual cycle noted to have normal
intervals occuring 3-4 days utilizing 2-3 pads/day with accompanying dysmenorrhea. Not sexually
active.

FAMILY HISTORY
The patient’s mother and father have hypertension. Maternal Grandfather died from DM. No
family history of stroke, heart dse, TB, allergy, asthma, gout, arthritis, CA, mental illness, thyroid dse.

PERSONAL AND SOCIAL HISTORY

Born and raised in Surigao. First year college at DDC, BSN. Patient is a nonsmoker and
nonalcoholic with good interrelationship with classmates and family. Dorm room is in the 4th floor
and is air-conditioned with screened windows with in-room latrine. Room is shared with 3 others and
was noted not ill. Classmates were also noted not ill.

REVIEW OF SYSTEMS

General: no weight changes

Skin: reddish non-raised round rashes were noted. No discoloration. Hypertrophic scar was noted in
the left knee.
Head: No history of head injury.
Eyes: No visual dysfunction, pain or redness.
Ears: Hearing is good. No tinnitus, infection or discharge.
Nose and Sinuses: No obstruction, epistaxis, or discharge. No sinus troubles.
Mouth, Throat: no soreness, or tonsilitis. No bleeding gums. Good dentition.
Neck: No lumps, goiter, pain. No swollen glands.
Breast: No lumps, pain, or discharge.
Respiratory: No cough, wheezing, dyspnea.
Cardiovascular: No known heart disease or high blood pressure. No dyspnea, chest pain, palpitations.
Has never had an electrocardiogram.
Gastrointestinal: Appetite is good. No nausea, vomiting, indigestion. No diarrhea or bleeding. No
pain, jaundice, gallbladder or liver problems.
Urinary: No frequency, dysuria, hematuria.
Genital: No vaginal or pelvic infections.
Peripheral vascular: No varicose veins. No edema. No history of phlebitis or leg pain.
Musculoskeletal: No joint pain, muscle pain, cramps. No weakness, trauma, stiffness.
Psychiatric: No history of depression or treatment for psychiatric disorders.
Neurologic: No fainting, seizures, motor or sensory loss. Memory is good.
Hematologic: No easy bleeding. No anemia. No past transfusion.
Endocrine: No known thyroid disorders or heat or cold intolerance. No symptoms or history of
diabetes.

PHYSICAL EXAMINATION
Vital Signs
Blood Pressure: 100/60 left arm in sitting position
Temperature: 36.9C
 Respiratory Rate: 26cpm
Heart Rate: 88bpm
Anthropometric Measurements
Weight: 49 kg
Height: 165 cm
BMI: 18 kg/m2
General description: Patient was examined conscious while being given IV fluids. Patient appeared
to be alert and was able to sit, stand and walk on her own. Patient responds quickly to questions.
Skin: Patient had reddish non-raised round rashes approximately 3-5mm in both lower legs. The skin
was warm to touch and good skin turgor. There were no discolorations but there was a hypertrophic
scar in the left knee region.
Lymph nodes: the cervical, submental, submandibular, pre and postauricular, occipital, infra and
supraclavicular, axillary and inguinal lymph nodes were non palpable.
Head:
Inspection: there were no deformities and the position of the skull was central in proportion to
the neck and the body, there were no irregularities near the suture lines. The hair was well distributed,
texture of the hair was fine and there was no pattern of loss. The scalp revealed absence of any
scaling, lumps, lesions or scars. The face was pale with normal contour and no pigmentations. Face
was symmetrical. No swelling or tenderness over the tempero-mandibular joint. The external nose
was symmetrical and no deformities on the nasal bridge and nares. Nasal septum was in the midline.
Palpation: there was no tenderness or masses felt upon palpation of the skull and scalp. There
was no pain and tenderness upon palpation of the frontal and maxillary sinuses. No pain felt on
palpation of the TMJ. No tenderness felt on the masseter, temporal and pterygoid muscles.
Range of motion: patient was able to jutt the mandible forward, lateral and side to side with no
difficulty.
Eyes:
Inspection: normal position and alignment of eyes. Eyebrows were full with uniform hair
distribution and no scaliness. No edema or lesions in the eyelids. No nodules or swelling in the
conjunctiva and sclera. Sclera appeared white and the conjunctiva was pinkish. No opacities in the
cornea. No shadows in the iris. Normal and equal size of the pupils. The pupils were round and
symmetrical.
Performed tests: accommodation and consensual reflexes were intact. Pupils were 4mm
constricting to around 2mm, round, and equally reactive to light. No weakness in the extraocular
muscles. Patient was able to read the Jaeger’s chart at no.5 in the right eye and no.3 in the left eye.
Ophthalmoscope finding showed a red orange reflex, distinct margins with non-tortuous vessels, no
haemorrhages or exudates, normal cup to disc ratio 0.2, arteries to vein ratio was 1:3.
Ear:
Inspection: auricle showed no deformities, lumps or skin lesions. No discharges.
Palpation: movement of the tragus was not painful. Anterior, infra and post auricular area
was non tender.
Performed tests: patient had good auditory acuity with the whispered voice test. Patient was
not able to lateralize sound which is considered normal for Weber’s test. Rinne’s test showed that air
conduction lasted longer than the bone conduction. Fundoscopy of the ear showed presence of
cerumen, no foreign bodies, non perforated ear drum and a cone of light.
Mouth:
Inspection: the lips were pale and not cracked. There was absence of scaling, ulcers and
masses. The oral cavity was pinkish, there were no ulcers or nodules. The gums were pinkish. No
signs of bleeding in the gums and no swelling or gingivitis in the interdental papillae. Teeth appeared
white in color. The tongue was pinkish and was symmetrical, smooth texture of the dorsum of the
tongue. Tongue was in midline and no deviation was observed. The floor of the mouth appeared
pinkish. Tonsils were not enlarged.
Upon performing the Aaaahh test, uvula stayed in the midline and palate rose up.
Neck:
Inspection: the neck was symmetrical. There was no venous distension. Thyroid organ moved
upon deglutition.
Palpation: absence of enlargement of the preauricular, posterior auricular, occipital, tonsillar,
submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular
lymph nodes. Trachea was in the midline, no deviation. The thyroid gland was soft and there were no
nodules or tenderness felt. No pain felt upon palpation of the cervical spine, trapezius muscles and
muscles between the scapulae.
Auscultation: no stridor over the trachea, tracheal sounds were heard, no bruits over the
thyroid gland.
Range of motion: patient was able to touch her chin to her chest, tilt head back and front, left
and right with no difficulty.
Shoulders:
Inspection: no deformities, scars or lesions in the clavicles, anterior and posterior shoulders
and scapulae.
Palpation: no tenderness felt in the sternoclavicular and acromioclavicular joints.
Range of motion: no difficulty in raising or depressing shoulders. No pain felt in raising arms
over head, sideways and in front of the body.
Chest and Lungs:
Inspection: there was no lung deformities or asymmetry. There were no abnormal retractions
or other impaired respiratory movements.
Palpation: no tenderness felt. No masses or sinus tracts. Symmetrical chest expansion. No
tactile fremitus.
Percussion: lung fields were resonant.
Auscultation: Normal breath sounds were heard. Vesicular sounds heard over both the lungs,
bronchial sounds heard over the manubrium and bronchovesicular sounds heard between the scapulae.
No adventitious sounds such as crackles, wheezes and rhonchi.
Special tests: in bronchophony, there were muffled and indistinct sounds. In egophony sounds
were “ee” and for the whispered pectoriloquy, faint and indistinct sounds were heard.
Cardiac: jugular venous pressure was measured 7 cmH20
 Inspection and Palpation: PMI was observed over the apex of the heart in the 4 th intercostal
space, about 4cm from the midclavicular line, approximately 2cm in diameter. PMI was small and
brisk. No palpable heaves and thrills.
Percussion: resonant in the lung areas and dull sounds over the 3rd, 4th and 5th interspace.
Auscultation: no murmurs heard.

Pulses Carotid Brachial Radial Femoral Popliteal Dorsalis Post

pedis tibial
Right Normal 2+ (2+) Not felt 1+ 2+ 1+
Left Normal 2+ (2+) Not felt 1+ 2+ 1+

Breast:
Inspection: breasts were symmetrical, skin tone color and normal contour. Texture was
smooth over the breasts and over the areolar region, no lesions were noted. Areola and nipples were
dark in color and there was an absence of nipple inversion or eversion. Absence of nipple retractions,
deviations and supernumerary nipples. No dimpling and no discharges were observed.
Palpation: no enlargement of axillary lymph nodes, no nipple compression. Absence of
lumps, nodules and masses.
Abdomen:
Inspection: no abdominal masses, scars, lesions or abnormal pigmentations.
Auscultation: normoactive bowel sounds heard. No bruits over the aorta and femoral arteries.
Percussion: liver dullness in midclavicular line. Abdomen was tympanic upon percussion. No
kidney tenderness felt over the right and left costovertebral angles.
Palpation: no pain felt upon light palpation. No pain felt upon moderate and deep palpation.
Liver border was felt at about 6cm midclavicular. Spleen was not palpables. Right and left kidneys
were non palpable. No guarding or rigidity of abdominal muscles.
Performance: patient was negative for murphy’s sign. Upon coughing, no pain was elicited.
Negative rovsing’s, psoas and obturator signs.
Peripheral vascular system:
Inspection: no scars or lesions in both arms from the fingertips to the shoulders, they were
symmetrical. Right hand was swollen over the area where the IV was being administered. Palms of
both hands were pale, nail beds were pale. Fingertips had no clubbing or cyanosis. Texture of skin
was soft. Skin temperature was warm to touch.
Rashes reddish in color, non-raised, round and approximately 3-5mm mm in size seen in the
lower legs. Legs were edematous extending to the foot area. Non pitting edema seen in the dorsum of
both feet. No scars or ulcers noticed. Skin temperature was warm to touch. Patient had no varicose
veins
Palpation: radial pulse was normal and strong (grade 2+) and similar in character in both
arms. No swelling or tenderness felt over the epitrochlear nodes. No tenderness felt in the external
surface of the ulna, olecranon process and epichondyles. No pain felt in the wrist joints, metacarpals
and over the proximal, middle and distal phalanges. No tenderness over the PIP and DIPs
 No enlargement or tenderness of superficial inguinal lymph nodes. Femoral pulse was not
felt. Popliteal pulse, dorsalis pedis pulse, posterior tibial pulse. Non pitting edema was present in the
dorsum of the foot. No edema over the medial malleolus and shins.
Range of motion: patient was able to bend and straighten elbows with no pain felt. Fingers
moved easily with no pain.
Spine and hips:
Inspection: vertebral column is aligned, no rashes or scars in the back.
Palpation: no pain or tenderness felt upon palpation of the spinous processes and sacroiliac
joints.
Range of motion: patient was able to bend forward, backward and laterally with no difficulty.
Genital and rectal exam: patient did not give consent.
Neurological:
Cerebellar tests: patient was able to perform rapid alternative movements with her hands with
fast speed, uniform rhythm and smooth movements. Patient accurately performed the finger to nose
test with no tremors. Heel to shin tests was smooth and accurate. Patient was able to maintain posture
and balance while walking.
Stance: patient was able to maintain an upright position in the Romberg’s test. There was no
inward movement of the forearm and arm in the pronator drift test.
Cranial nerves:
CN I: patient could distinguish smells and no nasal obstructions.
CN II: patient was able to read the Jaeger’s chart at
CN III,IV,V: extraocular muscles were intact and the patient can follow the movement of the fingers.
CN V: patient had positive corneal reflex, was able to distinguish between soft and sharp so intact
facial sensation, no difficulty in jaw movements.
CN VII: patient was able to raise eyebrows, frown, close eyes and smile
CN VIII: patient had positive whispered voice test and was able to repeat the letters and numbers.
CN IX,X: patient was able to swallow with no difficulty, there was rise of palate in the “Ahh test” and
intact gag reflex.
CN XI: patient was able to raise shoulders and move neck in the opposite direction with resistance.
CN XII: tongue was symmetrical and non-deviated, it was present in the midline.
Sensory system: pin prick, light touch, position sense was intact. Patellar reflex, biceps, triceps,
brachioradialis, Achilles reflexes were intact.
Motor system: no involuntary movements such as tremors, fasciculations or ticks. No atrophy or
wasting of muscles. Muscle strength was graded as 5, was able to contract against gravity and
resistance.
Special tests: negative brudzinski sign, negative kernig’s sign, negative Babinski sign
DISCUSSION:
 Dengue viruses cause symptomatic infections or asymptomatic seroconversion. Symptomatic
dengue infection is a systemic and dynamic disease and has a wide clinical spectrum that includes
both severe and non-severe clinical manifestations. After the incubation period, the illness begins
abruptly and, in patients with moderate to severe disease, is followed by three phases- febrile, critical
and recovery.

Febrile phase
Patients typically develop a high-grade fever suddenly. This acute febrile phase usually lasts
2-7 days and is often accompanied by facial flushing, skin erythema, generalized body ache, myalgia,
arthralgia, retro-orbital eye pain, photophobia, rubeliform exanthema and headache. Anorexia, nausea
and vomiting are common. Mild haemorrhagic manifestations such as petechiae and mucosal
membrane bleeding (e.g. of the nose and gums) may be seen. Easy bruising and bleeding at
venepuncture sites is present in some cases. Massive vaginal bleeding (in women of childbearing age)
and gastrointestinal bleeding may occur during this phase although this is not common.The liver may
be enlarged and tender after a few days of fever. The earliest abnormality in the full blood count is a
progressive decrease in total white cell count. Medical complication in this phase is dehydration.

Critical phase
During the transition from the febrile to afebrile phase, patients without an increase in
capillary permeability will improve without going through the critical phase. Instead of improving
with the subsidence of high fever; patients with increased capillary permeability may manifest with
the warning signs, mostly as a result of plasma leakage. These patients become worse around the time
of defervescence, when the temperature drops to 37.5-38°C or less and remains below this level,
usually on days 3–8 of illness. Progressive leukopenia followed by a rapid decrease in platelet count
usually precedes plasma leakage. An increasing haematocrit above the baseline may be one of the
earliest
additional signs. The period of clinically significant plasma leakage usually lasts 24-48 hours. A
rising haematocrit precedes changes in blood pressure (BP) and pulse volume. Medical complication
in this phase is shock from plasma leakage, severe haemorrhage and organ impairment.

Recovery phase
As the patient survives the 24-48 hour critical phase, a gradual reabsorption of extravascular
compartment fluid takes place in the following 48-72 hours. General wellbeing improves, appetite
returns, gastrointestinal symptoms abate, haemodynamic status stabilizes, and diuresis ensues. Some
patients have a confluent erythematous or petechial rash with small areas of normal skin, described as
“isles of white in the sea of red”. Bradycardia and electrocardiographic changes are common during
this stage. The haematocrit stabilizes or may be lower due to the dilutional effect of reabsorbed fluid.
The white blood cell count usually starts to rise soon after defervescence but the recovery of the
platelet count is typically later than that of the white blood cell count. Respiratory distress from
massive pleural effusion and ascites, pulmonary oedema or congestive heart failure will occur during
the critical and/or recovery phases if excessive intravenous fluids have been administered. Medical
complication in this phase is hypervolemia and acute pulmonary edema.

Warning signs of dengue

Warning signs usually precede the manifestations of shock and appear towards the end of the
febrile phase, usually between days 3–7 of illness. Persistent vomiting and severe abdominal pain are
early indications of plasma leakage and become increasingly worse as the patient progresses to the
shock state. The patient becomes increasingly lethargic but usually remains mentally alert. These
symptoms may persist into the shock stage. Weakness, dizziness or postural hypotension occur during
the shock state. Spontaneous mucosal bleeding or bleeding at previous venepuncture sites are
important haemorrhagic manifestations. Increasing liver size and a tender liver is frequently observed.
However,
clinical fluid accumulation may only be detected if plasma loss is significant or after treatment with
intravenous fluids. A rapid and progressive decrease in platelet count to about 100 000 cells/mm3 and
a rising haematocrit above the baseline may be the earliest sign of plasma leakage. This is usually
preceded by leukopenia (≤ 5000 cells/mm3).

Diagnostic Management
- full blood count and frequent haematocrit determinations (determines severity of plasma leakage)
- ultrasound (for detection of free fluid in the chest and abdomen)
-RTPCR for viral genome detection for acute dengue infection
Therapeutic management
-intravenous rehydration to replace fluid loss from fever
-adequate bedrest