Clinical Case Write Up Sample


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Clinical Case Write Up Sample

  2. 2. PATIENT’S IDENTIFICATIONR/N :Name : NurFatenSyuhadabinti MuhammadAge : 19 years oldAddress : KubangKerian, Kelantan.Gender : FemaleRace : MalayMarital status : SingleOccupation : StudentDate of Admission : 7/11/2012Date of Clerking : 7/11/2012Informant : Patient herselfCHIEF COMPLAINTThe patient NurFatenSyuhada Muhammad, a 19 year-old female Malay was presented toHUSM with the complaint of fever associated with sore throat, joints pain and vomiting 5days prior to admission(PTA).HISTORY OF PRESENTING ILLNESSShe was apparently well until 5 days ago when the fever developed. Regarding the fever, itwas of sudden onset and continuous in nature. It also associated with sore throat, sweating andjoint pain. She went to the general practitioner for treatment and was given antibiotics forboth fever and sore throat. The fever was apparent at night and early morning, not aggravatedbut relieved by taking Panadol. For the sore throat, it developed simultaneously with the fever. The generalpractitioner said her left tonsil was swollen so that she was given antibiotic to overcome theswelling. 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 poororal intake. In the first episode, the vomitus contained food material and was yellowish incolour. She denied any presence of blood in the vomitus. For the subsequent bouts ofvomiting, it was whitish and scanty in volume. The frequency of vomiting reported was twiceper day. She also stated she had a mild epigastric pain which radiates to the left hypochondriacregion. She gave the pain score of 2 out of 10 and claimed it was due to poor oral intake, lossof appetite and the vomiting bouts.
  3. 3. SYSTEMIC REVIEWSystem Sign & Symptom FindingsGenitourinary Dysuria No Hematuria NoDermatology Discolouration Slightly yellowish Rashes NoRespiratory Shortness of Breath No Cough No Sore throat Yes Nasal bleeding NoCardiovascular Chest pain NoGastrointestinal Nausea No Vomiting YesMusculoskeletal Yes, especially in lower Joint pain limbs Muscle pain NoCentral Nervous Blurring of vision No Photophobia No Drowsiness No
  4. 4. PAST MEDICAL AND SURGICAL HISTORYIn 2007, she was admitted to the hospital for liver biopsy due to marked ascites andabdominal pain. She was diagnosed to have autoimmune hepatitis.There is no history of blood transfusion and any other comorbidity.FAMILY HISTORYShe is the youngest out of two siblings. There is no similar history of the same illness in thefamily.SOCIAL HISTORYCurrently she is a student at a local college and lives in KubangKerian which is an endemicarea. She denied any recent contact with tuberculosis patient and also a non-smoker.DIET HISTORYShe had poor oral intake and loss of appetite. She denied any food allergies.DRUG HISTORYShe denied of any drug allergies.SEXUAL HISTORYShe denied any sexual intercourse or abuse.TRAVEL HISTORYShe had no recent travel history to other tropical and endemic areas.SUMMARYThis patient is 19 years-old female student with the history of autoimmune hepatitis wasadmitted to HUSM with the complaint of low grade fever associated with sore throat, jointspain, sweating and vomiting 5 days prior to admission.
  5. 5. PHYSICAL EXAMINATIONGeneral Inspection On inspection, she was alert and conscious. She was lying comfortably in supine andflat position supported by 1 pillow. There were no signs of gross deformity.There was acanula attached on the dorsum of her right hand. She was not in respiratory distress or inpain. She was nutritionally and hydrationally adequate.Vital SignsBlood Pressure : 121/54 mmHgTemperature : 37.5 degrees CelciusRespiratory Rate : 16 breath/minPulse rate : 56 beat/minPulse volume : AdequatePulse rhythm : RegularGeneral ExaminationHandThe 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 FacePresent 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. 6. ChestThe 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 limbsBothdorsalispedis and posterior tibialis pulses were palpable.Absent of ankle oedema or other deformity.Lymph NodesAll lymph nodes were normal, no enlargement.Specific Examination(Abdominal)InspectionThe 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.PalpationOn 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. 7. PercussionTroube’s space percussion was resonance.No shifting dullness or fluid thrills.No ballotable kidneys.AuscultationBowel sounds could be heard on all quadrants.No renal bruits.DIFFERENTIAL DIAGNOSISNo DDx Positive findings Negative findings1 Dengue fever Fever Rashes Headache Persistent vomiting Abdominal pain Jaundice Joint pain Hepatomegaly2 Malaria Headache Flu like illness Vomiting Myalgia Jaundice Diarrhoea Fever Cough Rashes3 Chikungunya Fever Conjuctivitis Joint pain Petechiae Photophobia Stiffness of joints4 Typhoid fever High grade fever Dry cough Headache Diarrhea Abdominal pain ConstipationPROVISIONAL DIAGNOSISDengue fever.
  8. 8. DISCUSSIONPATHOPHYSIOLOGY 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 Formation of antibody Release of cytokines (antigen-antibody complex from macrophages formed) (IL-1,TNF,IF-γ) Deposit in Deposit in the joint vascular Stimulate anterior Endothelial injury endothelium Trigger inflammatory hypothalamus response (↑PG synthesis) Rash ↑ thermo-regulatory Vasodilation of blood Joint pain (arthralgia) set point vessels fever ↑ cerebral fluid flow Deposit in small capillaries in eyes ↑↑ metabolic rate ↑ intracranial pressure Trigger inflammatory ↑↑ tissue activity & headache response protein breakdown (accumulate) Retro orbital pain Lactic acid accumulation Muscle pain (myalgia) Disseminated in liver Multiply in RES Hepatomegaly and spleen
  9. 9. INVESTIGATIONSFull 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. 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.COMPLICATIONIf severe, dengue fever can damage the lungs, liver or heart. Blood pressure can drop todangerous levels, causing shock and, in some cases, death.PREVENTION - Stay in air-conditioned or well-screened housing. Its 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.