University of Santo Tomas

Faculty of Medicine and Surgery

Department of Internal Medicine

ADMISSION
CONFERENCE
August 2019
CCIC Anna Regina E. Alcantara
GENERAL DATA
• M.S.E.
• 26 F
• Single
• Tondo, Manila
• Customer support

CC: Loss of appetite

HISTORY OF PRESENT ILLNESS
1 week PTA • Undocumented intermittent fever and chills
• (+) nausea, (+) altered taste (bitter), (+)
anorexia
• No change in daily activities
• No medications nor consultation done
• (-) abdominal pain, (-) jaundice, (-) vomiting, (-)
cough, (-) colds, (-) headache, (-)
dysphagia, (-) dysuria, (-) change in bowel
habits, (-) arthralgia, (-) rashes, (-) bleeding
episodes
HISTORY OF PRESENT ILLNESS
6 days PTA • Persistence of symptoms
• Self-medicated with Ibuprofen + Paracetamol (Alaxan)
200/325mg 1 tab every 6 hours and Paracetamol
(Biogesic) 500mg/tab 1 tab every 8 hours which afforded
slight relief
• Sudden 7/10 non-radiating dull lower back pain
persisted throughout the day
• Applied Methyl salicylate + Mentol + Tocopherol acetate
+ Camphor (Salonpas) medicated patches which afforded
slight relief
• Still no consult
• Travel to Boracay
HISTORY OF PRESENT ILLNESS
5 days PTA • Persistence of symptoms except lower back
pain
• 7/10 localized hip pain, relieved with
Salonpas medicated patches

4 days PTA • Hip pain resolved, now 7/10 bilateral thigh

pain
• Relieved with Salonpas
• (+) nonpruritic, nontender, macular rashes
• Initially on face then on UE and torso
HISTORY OF PRESENT ILLNESS
3 days PTA • Back to Manila
• Afebrile, resolution of chills and myalgia
• (+) 7/10 frontal throbbing headache,
persisted throughout the day and not
aggravated by light or movement
• (+) anorexia, nausea, weakness
• No consult, no medications/patches
HISTORY OF PRESENT ILLNESS
2 days PTA • Persistence of symptoms
• D1 Menstruation
• Heavier – 3-4 fully soaked pads

1 day PTA • Persistence of symptoms

• Rash now noted with whiter areas on UE
• (+) petechiae on LE
• Decreased menstrual bleeding
• 3 partially soaked pads
HISTORY OF PRESENT ILLNESS
Hours PTA • (+) bleeding while gargling mouthwash
• Persistence of anorexia and altered taste
prompted consult at ER-CD and subsequent
admission
• CBC 12:30PM: microcytic hypochromic anemia (Hgb 124
Hct 0.39 RBC 4.66 MCV 83.20 MCH 26.60), leukopenia
(3.40), borderline thrombocytopenia (170)
• Blood chemistry: hypokalemia (3.32), normal crea
(0.69) and Na (138), high AST (146.40) and ALT (119.20)
• CXR: clear lung fields, left costophrenic sulcus minimally
blunted, consider minimal pleural effusion
• (+) Dengue NS1 Ag, (+) Dengue IgM, (+) Dengue IgG
Admission
REVIEW OF SYSTEMS
• General Survey: conscious, coherent, (-) weight loss, (-) altered
sensorium
• Cutaneous: (-) pallor, (-) hair loss
• Eye: (-) eye pain, (-) blurring of vision, (-) eye discharge
• Ear: (-) discharge, (-) ear pain
• Nose: (-) colds, (-) epistaxis, (-) discharge, (-) obstruction
• Mouth: (-) fissures, (-) sores
• Throat: (-) sore throat (-) voice change (-) bleeding
• Neck: (-) dysphagia, (-) odynophagia
REVIEW OF SYSTEMS
• Cardiology: (-) chest pain, (-) palpitations
• Respiratory: (-) cough, (-) colds, (-) dyspnea
• Gastrointestinal: (-) diarrhea, (-) constipation
• Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold intolerance
• Genitourinary: (-) dysuria, (-) hematuria (-) lower urinary tract symptoms
• Neurologic: (-) headache, (-) seizures, (-) loss of consciousness
• Psychiatry: (-) change of behavior, (-) insomnia
• Musculoskeletal: (-) limited range of measure, (-) joint stiffness,
(-) swelling, (-) edema
PAST MEDICAL HISTORY
• Past illness:
• (-) HTN, (-) DM, (-) Thyroid disease, (-) Asthma, (-) Pneumonia
• no previous history of Dengue
• Known allergies: Acute contact dermatitis (June 2019)
• Prescribed Loratidine 10mg/tab 1 tab ODHS
• No previous accidents/surgeries
• No previous blood transfusion
• Reports “complete” vaccination, (-) Dengvaxia
• Menstrual history
• M: 12 y/o
• I: 28-30 days
• D: 3 days
• A: 1-2 days/d
• S: (-) dysmenorrhea, (-) diarrhea
• LMP: July 27
CURRENT HEALTH STATUS & RISK FACTORS
• Diet: Usually home-cooked meals, vegetables, pork and beef
• Water source: delivered purified water
• Nonsmoker, (+) smoking exposure, Father
• Occasional alcoholic beverage drinker
• No history wading in flood
• Recent travel to Boracay (June 2019, August 6-9, 2019)
• Denies illicit drug use
• No pets at home
• Current medications:
• None
• (-) Herbal use
• (-) Steroid use
• (-) Antibiotic use in the last 3 months
FAMILY HISTORY
• (+) Hypertension- Mother
• (-) Asthma
• (-) Stroke
• (-) Diabetes Mellitus
• (-) Cancer
• (-) Heart disease
• (-) Kidney Disease
• (-) Thyroid Disease
PERSONAL & SOCIAL HISTORY
• Lives with family but recently living near office for 15 days
• Good harmonious relationship with family
PHYSICAL EXAMINATION ON ADMISSION
• General Survey: conscious, coherent, not in cardiorespiratory distress
• Vital signs: BP: 100/60mmHg PR: 86 bpm, regular RR: 25 cpm
Temp: 36.5°C SpO2: 96% in room air
• Anthropometrics: Weight: 48 kg Height: 162.56 cm, BMI: 18.16
• Skin/Cutaneous: (+) rashes with white areas on UE (+) petechiae on
LE, (-) pallor, (-) jaundice, (-) cyanosis dry, warm skin
• Head: normocephalic, (-) bald hairless patches, (-) bumps or lesions
• Eye:, pink palpebral conjunctiva, (-) icteric sclera, pupil 2-3mm ERTL,
(-) conjunctival injection
• Ears: (-) gross lesions, (-) tragal tenderness, (-) aural discharge
*Taken with permission
PHYSICAL EXAMINATION ON ADMISSION
• Nose: nasal septum in midline, non-hyperemic nasal mucosa,
turbinates not congested, (-) nasal discharge, (-) mucosal lesions
• Mouth: moist buccal mucosa, uvula at midline, (-) gum bleeding,
(-) oral ulcers, (-) hyperemic and enlarged tonsils, (-) exudates, non-
hyperemic posterior pharyngeal wall, (-) gingival hypertrophy,
(-) tongue enlargement
• Neck: thyroid not enlarged, no palpable cervical lymphadenopathies,
trachea in midline, (-) neck mass, neck veins not distended
• Respiratory: symmetrical chest expansion, resonant on all lung fields,
equal tactile and vocal fremiti, clear breath sounds on both lung
fields.
PHYSICAL EXAMINATION ON ADMISSION
• Cardiovascular: adynamic precordium, apex beat at 5th LICS MCL,
loud S1 and soft S2 at apex, loud S2 and soft S1 at base, (-) heaves, (-)
lifts (-) thrills
• Gastrointestinal: Flat abdomen, normoactive bowel sounds (25),
tympanitic on all quadrants, no direct or rebound tenderness, no
bruit
• Genitourinary: no CVA tenderness
• Extremities: pulses full and equal on all four extremities, no edema,
no deformities, CRT <2 secs
SALIENT FEATURES
SUBJECTIVE OBJECTIVE
• 26, F who lives in Tondo, Manila • conscious, coherent, GCS 15 (E4M6V5), not in
cardiorespiratory distress
• Acute undocumented, intermittent fever, weakness, chills,
nausea, altered taste, anorexia, with bleeding episode • BP: 100/60mmHg PR: 86 bpm, regular RR: 25 cpm Temp:
36.5°C SpO2: 96% in room air
• 7/10 lower back pain, 7/10 hip pain, 7/10 bilateral thigh pain,
• Unremarkable HEENT, respiratory, CV, GI, GU
7/10 throbbing frontal headache
• microcytic hypochromic anemia (Hgb 124 Hct 0.39 RBC 4.66
• Nonpruritic, nontender macular rash on UE, later with white
MCV 83.20 MCH 26.60), leukopenia (3.40), borderline
areas thrombocytopenia (170)
• (-) abdominal pain, jaundice, vomiting, cough & colds, (-)
dysphagia, (-) dysuria, (-) change in bowel habits, (-) arthralgia

• (+) recent travel to Boracay

• Intake of Ibuprofen + Paracetamol (Alaxan) 200mg/325mg &

Paracetamol (Biogesic) 500mg/tab, application of Methyl
salicylate + Mentol + Tocopherol acetate + Camphor (Salonpas)

• Reports “complete” vaccination, (-) Dengvaxia

DIFFERENTIAL DIAGNOSIS
MEASLES INFLUENZA CHIKUNGUNYA DENGUE
High fever Acute fever Acute, (saddleback pattern), Acute fever (break-bone
Malaise Rhinorrhea high fever pattern)
Anorexia Sore throat Severe Arthralgia Severe myalgia
Cough Cough Chills Frontal/retroorbial headache
Conjunctivitis Conjunctivitis Abdominal pain Thrombocytopenia
Coryza Myalgia Anorexia Leukopenia
Koplik spots Arthralgia Headache Hemoconcentration
Lymphadenopathy Mild thrombocytopenia Nausea Elevated serum
Pharyngitis Slight elevation of Photophobia transaminases
Rash transaminases Migratory polyarthritis Hemorrhagic manifestations:
Elevated serum petechiae, mucosal bleeding
transaminases Back pain
Normal or slight leukocytosis Rash in 50% of cases; initially
Normal or mild diffuse and flushing; begins
thrombocytopenia on trunk and spreads
Normal hematocrit centrifugally
Pruritus
ADMITTING IMPRESSION

Dengue with warning signs

PLANS
• Admit to regular ward
• Diet: 30kcal/day 60% CHO 15% CHON 25% Fats divided into 3 meals
and 2 snacks; avoid dark colored food (adobong pusit, dinuguan,
chocolates)
• Monitor VS q4h and record
• WOF abdominal pain, persistent vomiting, signs of congestion, bleeding
• Monitor I&O qshift and record
• Serial CBC q6h
• Start with 240cc for 1-2 hours
 PLANS: DIAGNOSTICS
• CBC with platelet count
• Leukopenia
• Thrombocytopenia
• Hemoconcentration
• Bleeding parameters
• Na, K, Crea

Handbook for clinical management of dengue, WHO 2012

 PLANS: THERAPEUTICS
• Close monitoring
• Judicious volume replacement via IV therapy
• Isotonic solutions
• Start 5-7mL/kg/hr for 1-2h (240mL/hr)
• Reduce to 3-5mL/kg/hr for 2-4hr (144mL/hr)
• Reduce to 2-3mL/kg/hr or less (96mL/hr)
• Only for 24-48hrs

Handbook for clinical management of dengue, WHO 2012

THANK YOU!