Patient for discussion today is:
General Data: RD, a 30 year old, male, single, Roman Catholic, Filipino, currently residing in Metro Manila.
Chief Complaint: rashes
Profile: Patient is a non-diabetic. Known to have Prehypertension (According to JNC VII). He is a heavy smoker, and is an occasional alcoholic beverage drinker.
History of Present Illness:
The patient was apparently well until 8 days prior to consult, when he experienced low grade undocumented intermittent fever (Temperature undetermined). This was accompanied by low appetite and generalized body malaise, with no diarrhea, no vomiting, no headaches or abdominal pain. Patient sought consult with a relative who is a doctor, and was advised to increase oral fluid intake and to take Paracetamol 500 mg/tab 1 tablet q 4 for Temp greater than or equal to 37.8. Patient’s fever lysed 3 days prior to consult. It was also during this time when erythematous pruritic rashes started to appear all over his body. No medications were taken. No bleeding episodes such as melena, hematemesis, hematochezia occurred.
On the day of consult, Tourniquet test was done, which revealed a positive result.
Review of Systems:
General: (-) unexplained weight loss/gain (+) generalized weakness (+) anorexia
Skin: (+) rashes (-) jaundice (-) pallor (+) pruritus (-)ecchymosis (-) hematoma
Head and Neck: (-) masses (-) lymphadenopathy (-) headache (-) nape pain
Eyes: (-) icteric sclerae (-) blurring of vision (-) eye pain
Ears: (-) decreased hearing (-) ear pain (-) discharge
Chest and Lungs: (-) dyspnea (-) cough (-) colds
CVS: (-) palpitations (-) orthopnea (-) orthostatic hypotension
Abdomen: (-) abdominal pain (-) vomiting (-) nausea (-) diarrhea (-) melena/hematochezia (-) hematemesis
Extremities: (-) weakness (-) edema
Past Medical History:
Patient has not had a similar illness before. Patient has not had previous surgeries or hospitalizations.
(-) DM, HPN, Ca, Asthma
Personal and Social History:
(+) smoker
(+) alcoholic beverage drinker
Patient previously worked as a call center agent.
Diet is high in salt and fat. Lives in a crowded community with note of stagnant water in the surroundings.
Physical Examination
Vital Signs: BP 130/90 HR 90 RR 23 T afebrile
GS: awake, conscious, coherent, oriented to time, place and person, not in cardiorespiratory distress
SHEENT: warm, good turgor, anicteric sclerae, pink palpebral conjunctivae, (-) lymphadenopathy, no neck vein engorgement, no tonsillopharyngeal congestion, (+) HERMAN’S RASH
C/L: symmetric chest expansion, no retractions, clear breath sounds
CVS: adynamic precordium, normal rate, regular rhythm, no cardiomegaly
Abd: soft, flabby, normoactive bowel sounds, nontender
Ext: full and equal peripheral pulses, no cyanosis, no edema
ASSESSMENT:
Dengue Hemorrhagic Fever Grade I
CASE DISCUSSION:
This is a classic case of DHF I. It presented us with 5 day history of fever, with anorexia, followed by the appearance of Herman’s rash, a pruritic (itchy) red rash that spreads all over the body. A positive Tourniquet test strengthened my diagnosis. I did not do a CBC with platelet count anymore, since the patient is already 3 days without fever, and I am expecting the disease to be over soon. We would only classify the disease as Grade 2 if there are other signs of hemorrhage, such as melena or hematochezia (bloody stools) or hematemesis (bloody vomit) or gum bleeding or nose bleeding.
PLAN:
I educated the patient on the course of the disease. I told him to watch out for any signs of bleeding and abdominal pain (which could indicate internal bleeding) and further increase in weakness. I told him to keep eating, but to avoid dark colored foods so that we could easily determine if bleeding has occured. I gave him anti-pruritic medication for his rashes. If bleeding would occur, I advised him to get a CBC with platelet count done and to see me or my dad for us to determine if he needs to be confined in the hospital for fluids management.
The End.
P.S. Get well soon, kuya Ryan ^_^
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