1Chief Complaint: Fever

History of Present Illness:

The patient was apparently well until 3 days prior to consultation, the patient started to
experience undocumented fever that is accompanied with fatigue, headache, retro-orbital pain,
joint pain all graded with VAS of 4/10 and abdominal pain with a grading of 2/10. She self-
medicated with Paracetamol 500 mg taken every 4 hours which temporarily relieved her
symptoms. She also experienced excessive thirst and described her urine as dark yellowish
with decreased urinary output which the patient relieved with intake of glasses of water. She
denied chills, rashes, vomiting, cough, dyspnea___. No consultation was done.
2 days prior to consultation, the patient still experienced the undocumented fever,
headache, retro-orbital pain and joint pain, excessive thirst, dark urine with decreased output
but no abdominal pain. She continued the intake of Paracetamol 500 mg every 4 hours
temporarily alleviating her symptoms. No consultation was done.
1 day prior to consultation, still with persistent fever and associated symptoms, the
patient consulted to the nearest clinic from her house and her temperature was measured at 39
°C. She was not given any medications and recommended to continue intake of Paracetamol
but still not relieved her symptoms prompting the patient to seek another consult in our
institution.

Past Medical History: DONE

(-) Hypertension, diabetes, asthma, kidney disease
(-) Previous surgery, accidents, hospitalizations, blood transfusions
(-) Allergies to food or meds
(-) Intake of herbal supplements, vitamins or other alternative medications
(+) Complete immunization, unrecalled

Personal and Social History:

 Non-smoker
 Occasional intake of alcohol
 Lives alone in a well-ventilated rented room
 Works as a waitress in a restaurant for 3 years, works 8 hours/day, 7 days a week
 Frequently eats meat, and vegetables and seldom eats fish,
 Buys foods from market and restaurant and drinks water from NAWASA
 (+) History of travel to Palawan 3 weeks ago and stayed for vacation for 2 weeks
 Denies illicit use of drugs
 Coitarche at 20 y/o, had 1 sexual partner, currently non-sexually active

OB/Gyne History:
G0P0
(-) History of contraceptive use, Pap smear
(-) HPV vaccine
Menarche at 13 y/o, regularly menstruating every 28 th day of the menstrual cycle, lasting for 3
days, consuming 2 moderately soaked pads per day, no symptoms of dysmenorrhea, mood
changes and headache

Family History:
(-) Other family member with same illness
(-) Hypertension, diabetes
(-) Heart disease, lung disease, kidney disease, cancer

Review of Systems:
General: (-) changes in level of activity (-) changes in sleeping pattern (-) malaise (-) weakness
(-) changes in weight (-) loss of appetite (-) fatigability
Cutaneous: (-) pain (-) rash (-) pruritus (-) change in pigmentation (-) flushing (-) hair loss (-) nail
changes
HEENT: (-) headache (-) blurring of vision (-) visual loss (-) double vision (-) eye dryness (-) eye
pain (-) eye redness (-) hearing loss (-) tinnitus (-) drainage or otorrhea (-) loss of smell (-) nasal
congestion (-) epistaxis (-) loss of taste (-) mucosal dryness (-) sore throat (-) dysphagia (-)
odynophagia (-) neck pain
Respiratory: (-) cough (-) hemoptysis, (-) dyspnea
Cardiac: (-) syncope (-) palpitations (-) chest pain
Gastointestinal: (-) diarrhea, (-) constipation
Genitourinary: (-) frequency (-) dysuria (-) urgency (-) hematuria (-) nocturia (-) vaginal
discharge
Endocrine: (-) excessive sweating
Peripheral vascular: (-) numbness (-) varicose veins (-) discoloration of extremities
Nervous/Behavioral: (-) nervousness (-) anxiety (-) memory loss/confusion (-) behavioural
changes
Musculoskeletal: (-) leg cramps (-) difficulty walking
Hematologic: (-) bleeding (-) easy bruising

Physical examination: DONE

General Survey:  Conscious, coherent, ambulatory
Vital Signs: BP=140/80, HR=110/min, RR=20/min, T=39C
HEENT: Pink palpebral conjunctivae, anicteric sclerae
Neck: (-) neck vein engorgement, (-) cervical lymphadenopathy, (-) neck mass
Respiratory: equal chest expansion, no retractions, clear breath sounds
Cardiac: (-) heaves/thrills, AB at 5th LICS MCL, S1>S2 at the apex, (-) murmurs
Abdomen: globular abdomen, NABS, nontender, liver and spleen not palpable
Extremities: (+) mild calf tenderness, (-) edema, full pulses

INTERPRETATIVE SUMMARY
Our patient is a 28-year old Filipino female presented to the clinic after experiencing an
intermittent fever of acute-onset,

twisting quality, initially noted at the epigastric area but later radiating to back and shoulder and
becoming more prominent at the right upper quadrant, unrelieved by Mefenamic acid with
associated symptoms of constipation, diaphoresis, anorexia, vomiting of previously ingested
food but no rashes nor pruritus. Episodes of similar but mild epigastric pain had been recurring
within the previous 2 months, not aggravated nor relieved by eating, fasting or any change in
position and relieved by the aforementioned medication. Patient’s medical history revealed
hypertension but no diabetes, cardiovascular nor history of previous surgery, IV drug use and
blood transfusions. Her personal and social history was pertinent for frequently eating high level
of saturated fats but not a regular alcoholic drinker. She also had family history of hypertension
and diabetes but no history of heart diseases. Upon consultation, the patient was conscious,
coherent, and lying on right decubitus with knees flexed and her vital signs revealed that she
has low-grade fever, was hypertensive, tachycardic and tachypneic. Moreover, physical
examination confirmed presence of jaundice, direct epigastric tenderness but no rebound
tenderness, abnormal bowel sounds nor hepatomegaly and the rest of the patient’s history and
physical examination was unremarkable.

DIAGNOSIS DONE
Primary Working Impression: Dengue fever without warning signs
Differentials: Malaria
Typhoid fever
COVID-19

DISCUSSION
Dengue is categorized into 3 severity levels, namely, dengue infection (DF), dengue
hemorrhagic fever (DHF), and dengue shock syndrome (DSS). Risk factors of the patient such
as travel history to Palawan and history of dengue in their neighborhood strengthens the
suspicion of dengue. The dengue virus is transmitted to human by the bite of an Aedes
mosquito that is infected when they take up blood from other infected individuals. According to
the Department of Health-Epidemiology Bureau (DOH-EB), Palawan remains as the province
having the highest number of dengue cases in the MIMAROPA Region reported at the first
quarter of the year 2019. The patient reported that she had travelled to Palawan, stayed there
for 2 weeks and went back to her hometown 1 week prior to the onset of symptoms. After being
bitten by the infected mosquito, dengue symptoms usually begins abruptly after an incubation
period of 3-10 days which can explain the symptoms onset of the patient after returning from
Palawan. The patient also reported a dengue case in her neighborhood that happened a week
ago further supporting the diagnosis of dengue as the primary working impression. After the
incubation period, the course follows 3 phases, namely, febrile, critical, and convalescent. Along
with relapsing and persistent high fever, other associated symptoms are headache, retro-
orbital pain, joint pains and mild calf tenderness which are all presented by the patient.
Upon consultation, patient is on her fourth day of fever and currently on febrile phase that
usually lasts up to 7 days. Other symptoms of patient such as fatigue, polydipsia and dark
urine with oliguria but conscious and coherent, eupneic at 20 bpm, tachycardic at 110
bpm upon physical examination is attributable to mild to moderate dehydration which is usually
a complication of febrile phase. Once the fever subsides, the infection may progress to dengue
hemorrhagic fever with development of warning signs of severe disease manifested as severe
abdominal pain, persistent vomiting, hypothermia, rashes, bleeding gums, petechiae, other
hemorrhagic manifestations, and changes in mental status, thus, the diagnosis of dengue fever
must be first considered since this can be life-threatening to the patient once the critical phase
begins.
Malaria which is caused by

45 years of age, female gender with diet high in fat and cholesterol but low in
fiber, lack of regular exercise and family history of hypertension and diabetes strengthens
the suspicion of gallstone formation or cholelithiasis. These lifestyle and metabolic risk factors
cause an increase in triglycerides, decrease in high-density lipoprotein and increase in
cholesterol synthesis resulting to biliary secretion of cholesterol, and cholesterol
hypersaturation. In addition to this, estrogen increases cholesterol and its saturation in bile and
promotes gallbladder hypomotility. The excess cholesterol may precipitate as crystals which get
trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to
form stones and occlude the ducts which ultimately produce the gallstone disease.
Acute pancreatitis is an inflammatory condition of the pancreas that is most frequently
caused by gallbladder stones lodging in the Sphincter of Oddi leading to the obstruction of
pancreatic fluid flow. Subsequently, the blockage will cause the enzymes to collect in the
pancreas and begin to digest the cells of the pancreas, causing severe inflammation which is
attributed to abdominal pain of acute pancreatitis. The pain is sudden in onset and gradually
intensifies in severity until reaching a constant ache. It is usually located in the epigastric
region, prominently radiating to right upper quadrant and may radiates directly through the
abdomen to the lower back region which was also presented in the patient’s case that further
supports the diagnosis of acute pancreatitis as the primary working impression. Other
associated symptoms such as persistence of pain even after vomiting, diaphoresis and
anorexia and physical exam findings such as fever, tachycardia, tachypnea, epigastric
tenderness upon palpation and jaundice were also reported by the patient. Positioning is
also important in patients with acute pancreatitis because the discomfort frequently improves
with the patient curl up in a knee-to-chest (fetal position) by decreasing the stretch of the
pancreas and this was observed from the patient upon general examination.
On the other hand, acute cholecystitis, an inflammation of the gallbladder, is next to be
considered because it is also a complication of obstruction of the cystic duct by gallstones. It is
also closely related to acute pancreatitis in terms of risk factors and signs and symptoms.
Signs and symptoms reported by the patient include severe and prolonged abdominal pain (>
6 hrs) that usually begins in the epigastric region and then localized to the right upper
quadrant, vomiting, fever, anorexia, tachycardia, jaundice and pain radiate to the right
shoulder or scapula due to referred pain from phrenic nerve irritation. However, the absence
of rebound tenderness upon abdominal physical examination makes the acute cholecystitis
less likely the diagnosis.
Another complication of gallstone is Acute Cholangitis which is a bacterial infection
superimposed on an obstruction of the biliary tree most commonly from a gallstone. This must
also be considered since it is a medical emergency and the patient presented with classic triad
of acute cholangitis which are right upper quadrant (RUQ) pain, fever, and jaundice.
However, the patient only had low-grade fever which is different from the high-grade fever of
patients with acute cholangitis, thus this diagnosis is less likely in our patient but still, must be
considered because it is a life-threatening condition.
Lastly, Hepatitis, an inflammation of the liver, was considered because the patient
presented with jaundice as manifested by icteric sclerae upon physical examination. The patient
also presented with low-grade fever, anorexia, vomiting and right upper quadrant
abdominal pain. However, it is less likely because the patient had no rashes, joint pain, no
hepatomegaly, no palpable liver edge, no history of IV drug use and blood transfusion
and had complete immunization.

PROBLEM LIST and MANAGEMENT PLAN DONE

1. Fever
Diagnostics:
Tourniquet test- positive result indicates an increased probability of dengue than non-
dengue febrile diseases.
 Considered positive if ≥20 petechiae per square inch, 1.5 inches from volar
aspect of the antecubital fossa.
Virus or Bacterial Detection and its components:
 Dengue NS-1 antigen (rapid) test- marker of acute dengue infection, can be
used up to 4th day of illness
 Thin and thick blood smear- laboratory confirmation of Malaria, acute
demonstration of the parasite in the smear
  Blood culture- gold standard for typhoid fever, can be taken anytime during the
illness but yield highest during the first two weeks
 Rapid Antibody test- initial test for COVID

Complete blood count and hematocrit:

 Dengue: leukopenia, thrombocytopenia and elevated hematocrit which

represents onset of plasma leakage
 Malaria: normocytic normochromic anemia, thrombocytopenia
 Typhoid fever: neutropenia, leukopenia/cytosis, thrombocytopenia

Therapeutics:
Depending on the findings, treatment may include:
A) Dengue fever without warning signs:
a. Patients with stable hematocrit can be sent home
b. Adequate bed rest
c. Adequate fluid intake
d. Paracetamol PRN (4g max per day)
e. Daily review for disease progression: decreasing WBC, defervescence and
warning signs until out of critical period

B) Dengue fever with warning signs:

(I considered to put this on management since the patient is currently on 4 th day of febrile phase and warning signs usually
develop once the fever subsides or in critical phase)

a. Referred for in-patient management

b. Hydration (see dehydration below)
 Encourage oral fluid intake if tolerated. If not, start intravenous
hydration
 Start with 5-7 ml/kg/hour for 1-2 hours
 Reduce to 3-5 ml/kg/hour for 2-4 hours
 If Hct remains the same or rises minimally, continue with 2-3 ml/kg/hr
for 2-4 hours
 If with worsening vitals and rapidly rising Hct, increase the rate of 5-10
ml/kg/hour for 1-2 hours
 Reduce IVF until Hct decreases baseline
 c. Monitoring
 Vital signs every 1-4 hours until out of critical phase
 Hct at baseline and every 6-12 hours
 Blood glucose and other organ function tests

C) Malaria
a. Chloroquine + Sulfadoxine Pyrimethamine- first line of treatment in probable
and confirmed falciparum malaria that is not severe

D) Typhoid Fever
a. Hydration and nutrition
b. Antipyretics
c. Antimicrobial therapy
 Ceftriaxone 2g/day IV for 10-14 days or
 Azithromycin 1g/day PO for 5 days

E) COVID
a. Home isolation
b. Supportive care with adequate fluids and proper nutrition
c. Antipyretics

REFERENCES:
Harrison, T.R., Resnik, W.R., Wintrobe, M.M., et al. (2018)

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PERSONAL REFLECTIONS: Please include this reflection in your written report.

1) Please rank the following components for this activity from 1-5 (with 1 being the easiest, 5
hardest):
1 organizing case presentation
2 organizing written report
3 bedside history-taking and physical exam
4 discussion of differential diagnosis
5 generating problem list and plan

2) What made your #1 activity easy? What made your #5 activity difficult?
Organizing case presentation is the easiest since I am already in my third year and this has
been always a practice for medical students like us to present the case accordingly. Whereas, in
generating the problem in patient, you must think carefully because the treatment, interventions
and management plans must also coincide with the diagnosis. We cannot also treat the patient
in a generalized manner; thus, doctors should make individualized interventions to each of their
patients for them to achieve the optimal health care.

3) What improvements can you make for your performance in the next activity?
First, more organization in terms of history taking so that we won’t forget about asking
something and time management to do more searching about differential diagnosis, probable
diagnosis and plans.