This patient presented with a 5-day history of constant high fever associated with headaches, muscle weakness, vomiting, diarrhea, and vaginal bleeding. On examination, the patient's abdomen was tender all over, especially in the epigastric region. Lung percussion was dull in the lower zones bilaterally. A provisional diagnosis of dengue hemorrhagic fever with gastritis was made based on the classic symptoms of dengue such as the fever pattern, associated symptoms, vomiting, diarrhea, menorrhagia, and abdominal tenderness on examination.
Original Description:
Some example of case write-up for medical student for my friends reference
This patient presented with a 5-day history of constant high fever associated with headaches, muscle weakness, vomiting, diarrhea, and vaginal bleeding. On examination, the patient's abdomen was tender all over, especially in the epigastric region. Lung percussion was dull in the lower zones bilaterally. A provisional diagnosis of dengue hemorrhagic fever with gastritis was made based on the classic symptoms of dengue such as the fever pattern, associated symptoms, vomiting, diarrhea, menorrhagia, and abdominal tenderness on examination.
This patient presented with a 5-day history of constant high fever associated with headaches, muscle weakness, vomiting, diarrhea, and vaginal bleeding. On examination, the patient's abdomen was tender all over, especially in the epigastric region. Lung percussion was dull in the lower zones bilaterally. A provisional diagnosis of dengue hemorrhagic fever with gastritis was made based on the classic symptoms of dengue such as the fever pattern, associated symptoms, vomiting, diarrhea, menorrhagia, and abdominal tenderness on examination.
10500! "ear ! #nternal $e%icine #D&'(#F#C)(#*' D)() 'ame : 'a+,a bt )hma% 'a-ri )ge : 1. years ol% Se/ : Female Race : $alay Religion : #slam Registration 'o0 : )$00012. )%%ress : 3an%an #n%ah *ccupation : Cler4 in a clinic $arital Status : 'ot marrie% Date o5 a%mission : 26076007 Date o5 %ischarge : 816076007 Date o5 cler4ing : 16076007 Source o5 cler4ing : 3atient CH#&F C*$39)#'( Fever 5or the last . %ays be5ore a%mission: associate% ,ith vomiting an% muscle ,ea4ness H#S(*R" *F 3R&S&'(#'; #99'&SS Her 5ever starte% since . %ays ago an% it ,as constant0 #t is aggravate% at night ,ith shivering0 (he 5ever is associate% ,ith hea%ache: myalgia an% muscle ,ea4ness: arthralgia: bac4 pain: loss o5 appetite: loss o5 ,eight: rigor an% chills: retro<orbital pain: restlessness at night: vomiting: %iarrhea: per<vaginal blee%ing: syncopal attac4: light sensitivity: sore throat: cough an% %yspnoea: generali-e% ab%ominal pain especially at the epigastric region an% pain in the suprapubic an% loin regions0 (he vomiting also starte% on the same %ay as the 5ever0 #t ,as also constant 5or . %ays0 #t varies ,ith time an% came =uite 5re=uently0 (he content o5 the vomitus is ,hitish mucous an% some 5oo% an% the amount also varies0 (he vomiting is associate% ,ith shortness o5 breath an% epigastric pain0 Ho,ever: the vomitus has no bloo% stain0 (he episo%es o5 %iarrhea starte% on the ! th %ay o5 5ever0 (he 5re=uency is t,ice a %ay0 #t is ,atery %ar4 bro,n ant the amount also varies0 #t is not associate% ,ith any bloo% stain or any pain0 $ean,hile: the per<vaginal blee%ing is characteri-e% as intermenstrual perio%0 (his is because it state% on the ! th %ay o5 the 5ever0 #t is to be an abnormal perio% because she alrea%y ha% her perio% 5or this particular month in 7 th o5 )ugust 0070 She never ha% any history o5 similar episo%es an% it is sai% that her menstrual cycle is regular every month0 >esi%es: her regular menstrual cycle usually laste% only 5or 8 %ays: but this time it ,as still blee%ing even though it ,as alrea%y on the 5 th %ay0 During this particular episo%e: 8 pa%s ,ere 5ully soa4e% compare% to her regular menstrual cycle ,here on only an% hal5 pa%s soa4e%0 Her 5ever is not associate% ,ith any history o5 travelling:rashes: epista/is: gum blee%ing: pleuritic pain: haemoptysis: purulent sputum: haematuria: %ysuria: urgency: strangury an% nec4 sti55ness0 Due to the 5ever: she ,ent to ;eneral 3ractitioner 8 times0 *n 5irst %ay o5 5ever: she ,as given antibiotics an% pain 4iller0 )s the 5ever %oesn?t subsi%e: she ,ent again to the ;eneral 3ractitioner on the 8 r% %ay o5 5ever: an% ,as given another type o5 antibiotic yet the 5ever %i% not subsi%e0 So: she ,ent again to the ;eneral 3ractitioner on the 7 th %ay o5 5ever ,here she %i% a bloo% test0 Without 4no,ing the bloo% test result: she ,as re5erre% to Hospital )mpang %ue to suspecte% %engue 5ever0 S"S(&$#C R&@#&W Cardiovascular system She ha% %ypsnoea0 Ho,ever: there ,ere no chest pain: palpitation: orthopnea an% paro/ysmal nocturnal %ypsnoea0 Respiratory system She ha% sore throat an% non< pro%uctive cough0 She also ha% shortness o5 breath everytime a5ter vomiting0 'o heamoptysis0 Gastrointestinal system She ha% vomiting 5re=uently an% %iarrhea t,ice a %ay0 She also ha% generali-e% ab%ominal pain especially at the epigastric region0 'o hematemesis0 Genitourinary system She ha% suprapubic pain an% per<vaginal blee%ing Aintermenstrual blee%ingB0 >ut: there ,ere no %ysuria: polyuria: poly%ypsia: hematuria: urgency: s,ollen an4le or urinary incontinence0 Musculoskeletal System She complaine% o5 myalgia: muscle ,ea4ness: arthralgia: bac4pain an% rigor an% chills0 Ho,ever: there ,ere no muscle sti55ness an% abnormal gait0 Central Nervous System She ha% hea%ache: light sensitivity: restlessness at night an% syncopal attac40 >ut: there ,ere no tremor: loss o5 sensory: %iplopia: 5it: paralysis: speech %e5ect or bo%y incoor%inations0 3)S( $&D#C)9 H#S(*R" (he patient ha% history o5 bronchitis in the en% o5 Cune 0070 #t ,as treate% ,ith nebuli-er0 She also ha% gastritis ,hich ,as %iagnose% in 001 by a ;eneral 3ractitioner0 She is compliance to her me%ication but no en%oscopy ,as %one0 She ha% no other me%ical illness such as Diabetes $ellitus: Hypertension: #schemic Heart Disease an% asthma0 She ha% been a%mitte% t,ice in Hospital Dlang in 001 %ue to high 5ever an% the other ,as in 005 %ue to an acci%ent0 3)S( SUR;#C)9 H#S(*R" She ha% no past surgical history0 DRU; H#S(*R" She ha% 3aracetamol an% some antibiotics 5or her 5ever be5ore she came to Hospital )mpang0 She is currently on a long term me%ication 5or her gastritis but she only ta4es it ,henever necessary0 (he me%ication ,ere (agamet ACimeti%ineB: $e/alone an% >uscopan0 She also ha% no 4no,n %rug allergies or other 4no,n allergies0 F)$#9" H#S(*R" >oth her parents are still alive0 Her 5ather is !1 years ol% an% is having brain tumor0 $ean,hile her mother is 52 years ol% an% is having asthma an% a uterus problem ,hich she coul% not name it0 She has no siblings0 S*C#)9 H#S(*R" She is currently living ,ith 5rien%s in 3an%an #n%ah: ,hich is 4no,n to be an area o5 5ogging0 (hey live in a shop house at level 8 ,hich has no elevator an% she ha% no problem in climbing up the stairs0 She is not marrie%0 She is a non smo4er an% %rin4er0 She also ha% no se/ual promiscuity *>S(&(R#CS )'D ;"')&C*9*;#C)9 H#S(*R" Her menarche is at the age o5 1 years ol%0 Her menstrual cycle is regular ,hich usually lasts 5or 8 %ays0 3H"S#C)9 &E)$#')(#*' ;eneral e/amination *n inspection: patient ,as lying 5lat: loo4e% com5ortably an% ,ell0 She ,as ,ell orientate% to time place an% person0 (here ,as a cannula on the %orsum o5 the right han% ,hich ,as connecte% to a normal saline0 Her vital signs ,ere >loo% pressure : 11610 mmHg 3ulse rate : 1 beats per minute: regular an% normal volume Respiratory rate : 0 breaths per minute (emperature : 87 0 C *
saturation : .2F on air
(here ,ere no 5acies abnormalities: muscle ,asting: scars or any other abnormalities0 (here ,ere also no signs o5 +aun%ice: pallor or cyanosis0 3atient ,as 5airly hy%rate%0 Hand Warm: no e/cessive s,eating: capillary 5illing time ,as less than secon%s: no 5inger clubbing: no nicotine stain: no rashes or petechiae0 Hess test ,as not %one0 Eye 'o signs o5 pallor on the con+unctiva an% no +aun%ice0 Mouth 'o central cyanosis: no gum blee%ing an% hy%ration ,as 5air0 Neck 'o lympha%enopathy: no nec4 sti55ness an% +ugular venous pressure ,as not raise%0 Lower limb 'o rashes or petechiae: no an4le e%ema0 Specific physical examination )b%omen #nspection: )b%omen is 5lattene%: not %isten%e% an% umbilicus ,as centrally locate% an% inverte%0 #t moves ,ith respiration0 (here ,ere no scratch mar4s: obvious mass: %ilate% veins or any obvious peristaltic activities0 #nguinal ori5ices ,ere intact0 3alpation: *n super5icial palpation: the ab%omen ,as so5t an% =uite ten%er on all . regions especially at the epigastric region0 'o reboun% ten%erness: guar%ing: rigi%ity an% mass ,ere 5oun%0 *n %eep palpation: no organomegaly %etecte%0 3ercussion: )b%ominal resonance ,as presence ,ith no ascites0 )uscultation: >o,el soun% ,as hyperactive an% no renal bruit ,as hear%0 Respiratory system #nspection: Chest move% bilaterally symmetrical ,ith respiration0 Chest ,as normal in shapeG no 4yphosis: no scoliosis an% no lor%osis0 'o %ilate% veins an% no surgical scars0 3alpation: Chest e/pansion ,as e=ual in both si%es0 @ocal 5remitus ,ere re%uce% at the lo,er -ones on both si%es0 3ercussion: 9ung percussion ,as %ull on the lo,er -ones o5 both si%es0 *ther parts ,ere resonance0 )uscultation: >reath soun% ,as normal ,hich ,as vesicular breath soun%: air entry ,as e=ual bilaterally: no ,hee-ing: no crepitation: no pleural rub an% other a%%e% soun%s0 @ocal resonance ,as re%uce% at the lo,er -ones on both si%es0 Systemic examination Car%iovascular system #nspection: )pe/ beat coul% not be seen0 (here ,as also no scars: precor%ial bulge an% e/tra pulsation observe%0 3alpation: (he ape/ beat ,as present at the 5 th intercostal space at the mi% clavicular line ,ith normal character0 3alpable murmur AthrillsB an% heaving ,ere absent0 'o other pulsation 5oun%0 )uscultation: (he 5irst an% secon% heart soun%s ,ere present an% normal0 (here ,as no murmur an% a%%e% heart soun% hear%0 $usculos4eletal system *n inspection: no s4ull: long bones an% spine %e5ormities observe%0 (here ,as also no bone %e5ormities: ten%erness: muscle ,asting an% s,elling present at the +oints0 #n a%%ition: there ,ere also no abnormal movements %etecte%0 Central 'ervous system 3atient ,as conscious: alert an% ,ell oriente% ,ith time: place an% person0 (he speech: cranial nerves: sensation: motor 5unction an% re5le/es: cerebellar 5unction an% gait ,ere normal0 C)S& SU$$)R" ) 1. year<ol% $alay la%y: came in ,ith history o5 constant 5ever 5or . %ays associate% hea%ache: myalgia: bac4pain: retro<orbital pain: ,ea4ness: restlessness: loss o5 appetite: chills an% rigor: She also ha% vomiting: %iarrhea: pervaginal blee%ing: syncopal attac4: light sensitivity: sore throat: cough: %yspnoea: generali-e% ab%ominal pain especially at the epigastric region: suprapubic region pain an% loin pain0 3hysical e/amination sho,s that there ,as slight ten%erness on all . regions o5 the ab%omen especially at the epigastric area0 9ung percussion ,as %ull at the lo,er -one on both si%es0 (he vocal 5remitus: air entry an% vocal resonance ,ere re%uce% at the lo,er -one on both si%es0 3R*@#S#*')9 D#);'*S#S Dengue haemorrhagic fever with gastritis. Reasons 5or %engue haemorrhagic 5ever: <Constant 5ever 5or . %ays < 3resence o5 the associate% symptoms o5 a viral 5ever < vomiting < %iarrhea < menorrhagia < syncopal attac4 < light sensitivity < sore throat: cough an% %yspnoea < generali-e% ab%ominal pain esp0 at epigastric region < suprapubic region pain < loin pain <9iving in en%emic area <Fever ,ith menorrhagia <Signs o5 pleural e55usion Asigni5y plasma lea4ageB Reasons 5or gastritis: <)b%ominal pain especially at epigastric region <@omiting <Diarrhea D#FF&R&'(#)9 D#);'*S#S 1B (yphoi% 5ever Reasons 5or: <patient ate outsi%e 5oo% <intermittent 5ever: hea%ache an% ab%ominal pain <ab%ominal ten%erness Reasons against: <no hepatosplenomagaly: no lympha%enopathy an% no scanty maculopapular rashes <absence o5 bra%ycar%ia at the pea4 o5 5ever B $alaria Reasons 5or: <5ever: hea%ache: vomiting an% %iarrhea <rigors Reasons against: <temperature %i% not reach up to !1 0 C <absence o5 classical tertian or =uartan 5ever <no hepatosplenomegaly 8B Chi4ugunya Reasons 5or: <arthralgia: 5ever an% myalgia Reasons against: <rare in $alaysia but common in #n%ian *cean islan%s !B 9eptospirosis Reasons 5or: <5ever: hea%ache: myalgia: Reasons against: < no e/posure to ,ater contaminate% ,ith animal urine <absence o5 hepatosplenomegaly an% lympha%enopathy #'@&S(#;)(#*' (he investigation planne% on her as belo,: F>C< Hb: Haematocrit: W>C: 3latelet )>* ;roup )ctivate% 3artial (hromboplastin (ime Dengue #g$ 3( #'R 9iver Function (est A9F(B Renal 3o5ile Wi%al (est Chest E<Ray (&S( R&SU9(S 1iB F>C< Hb: Haematocrit: W>C: 3latelet an% others A%one on 26076007B *b+ective: (o loo4 speci5ically 5or the ,hite bloo% cells count: platelet an% haematocrit level 5or %engue in5ection0 white blood cells : 3.7 K/uL platelet : 10 K/uL mean platelet volume : 1201 59 re% bloo% cells : !02. haemoglobin : 1501 g6%9 haematocrit : !. " mean cell volume : .20. 59 mean cell haemoglobin : 80 pg mean cell haemoglobin concentration: 880g6%9 #mpression: (he ,hite bloo% cells an% the platelet count are %ecrease%: but haematocrit level is still in normal range0 $ean platelet volume: mean cell volume an% mean cell haemoglobin are raise% too0 *ther rea%ings are normal0 1iiB F>C< W>C: 3latelet an% haematocrit A%one on 16076007: 76076007 an% .6076007B *b+ective: (o loo4 speci5ically 5or the pattern o5 ,hite bloo% cells count: platelet an% haematocrit level 5or %engue in5ection0 1607607 7607607 .607607 02:. 18:1 02:00 0.:55 11:58 00:!8 05:!. 1!:51 White bloo% cells AD6u9B 202 70! 20. 20. 201 508 501 !01 3latelet AD6u9B 12 0 1 1 1 1 11 8 HaematocritAFB !200 !102 8101 8708 8101 850 850 8507 #mpression: (he ,hite bloo% cells count ,as in normal range throughout the 8 %ays0 (he platelet level ,as still lo, ,hile the haematocrit level ,hich ,as normal at the beginning starte% to %ecrease on the . th o5 )ugust 0070 (he results o5 Full bloo% count on 80 th )ugust 007 an% 81 st )ugust 007 coul% not be obtaine%0 B )>* ;roup A%one on 16076007B *b+ective: to %etect patient?s bloo% group in case 5or any bloo% trans5usion0 >loo% group : * Rh ;roup : D positive #mpression: (he patient has an * an% Rh positive bloo% group 8B )ctivate% 3artial (hromboplastin (ime A)3((B A%one on 16076007B *b+ective: (o see coagulation time0 )3(( : 501 sec #mpression: (he )3(( is raise% !B Dengue #g$ A%one on 16076007B *b+ective: (o loo4 5or any recent Dengue in5ection Dengue #g$ : %etecte% #mpression: Suggestive o5 a recent %engue in5ection 5B 3( #'R A%one on 16076007B *b+ective: (o see coagulation pro5ile 3rothrombin ratio : 100 sec #nternational 'ormalise% Ratio A#'RB : 100! #mpression: (he prothrombin ratio is normal ,hile the #'R is %ecrease% 2B 9iver Function (est A9F(B A%one on 16076007B *b+ective: (o see any liver impairment (otal protein : 20.8 umol69 )lbumin : 1 g69 ;lobulin : 1g6%9 )lbumin6;lobulin ratio : 1000 )l4aline phosphatise : !0 U69 )lanine (ransaminase AS;3(B : 81U69 #mpression: )lbumin is %ecrease% 1B Renal 3o5ile A%one on 16076007B *b+ective: (o see any renal impairment Urea : 10.0 mmol69 So%ium : 181 mmol69 3otassium : 802 mmol69 Chlori%e : 10. mmol69 Creatinine : 5 umol69 #mpression: @alues ,ithin normal range 7B Wi%al (est A%one on 16076007B *b+ective: (o loo4 5or evi%ence o5 typhoi% 5ever S0 3aratyphi aH 5lagellar : negative S0 3aratyphi bH 5lagellar : negative S0 (yphi %H 5lagellar : negative S0 (yphi * somatic )g : negative #mpression: (here ,as no evi%ence o5 typhoi% 5ever .B Chest E<Ray *b+ective: to see any lung consoli%ations an% car%iomegaly Result : <blunt costophrenic angle <heart ,as normal in si-e #mpression: >lunt costophrenic angle Aa sign o5 pleural e55usionB # ,oul% also li4e to propose some other relevant investigations such as: 1B >loo% culture: bloo% 5ilm *b+ective: (o loo4 5or evi%ence o5 malaria B Urine %ipstic4 *b+ective: (o loo4 5or any severe hypovolemia or any microscopic haemorrhage 8B Urine culture an% Sensitivity *b+ective: (o loo4 5or any urinary tract in5ection !B Sputum Culture an% Sensitivity *b+ective: (o loo4 5or any upper respiratory in5ection 5B &n%oscopy *b+ective: (o loo4 5or any gastric or %uo%enal ulcer0 $)');&$&'( *n arrival at the emergency %epartment: patient ha% been given intravenous 'ormal Saline 1000 ml68 hours an% Hantac6$a/alon0 Full bloo% count is also being trace%0 )n hour later: patient is the me%ical ,ar%0 *n a%mission: the patient ha% been given 5 pints o5 intravenous 'ormal Saline ,hich ,as alternate% ,ith 1g DC90 She ,as also been given me%ication such as Raniti%ine tablets 150 mg t,ice a %ay: Duphaston tablets 1 tablet once a %ay: Raniti%ine 150 mg t,ice a %ay: Rocephine 5or 5 %ays an% Flagyl as the patient has %iarhea an% high spi4ing 5ever0 Serial observation ,as %one on her i0e0 Full >loo% Count: Renal 3ro5ile: 9iver Function (est: 3rothrombin (ime an% )ctivate% 3artial (hromboplastin (ime Ato loo4 5or any blee%ing ten%encyB an% Dengue #;$0 Her 5ull bloo% count especially the haematocrit level is monitore% every ! to 2 hours or as clinically in%icate%0 Chest /<tray ha% also been %one on her since there ,ere signs o5 pleural e55usion on physical e/amination0 Due to her improvement: especially on the ,hite bloo% cells count: platelet level an% she ha% alrea%y been a5ebrile: she ha% been %ischarge% on 81 st o5 )ugust 007 an% ,as as4e% to come again to chec4 5or her improvement0 She ,as given )mo/y Clavulinic )ci% 25mg tablets t,ice a %ay: Ce5tria/one 1g #ntravenous in+ection once %aily: $etroni%a-ole 00mg tablet an% $etroni%a-ole 500m6100ml in+ection every 7 hours0 )ll her me%ication is 5or 5 %ays0 D#SCUSS#*' Dengue is the most common an% ,i%esprea% arthropo%<borne arboviral in5ection in the ,orl% to%ay0 (he geographical sprea%: inci%ence an% severity o5 %engue 5ever ADFB an% %engue haemorrhagic 5ever ADHFB are increasing in the )mericas: South<&ast )sia: the &astern $e%iterranean an% the Western 3aci5ic0 Some :500 million to 8:000 million people live in areas ,here %engue viruses can be transmitte%0 #t is estimate% that each year 50 million in5ections occur: ,ith 500:000 cases o5 DHF an% at least 1:000 %eaths0 Dengue virus is an )rbovirus that belongs to the 5amily Flaviviridae: un%er the genus Flavivirus0 #n the past: it ,as classi5ie% un%er the ;roup > )rboviruses0 #t is a small envelope% virus measuring 50 to 20 nm in si-e containing a single stran%e% positive sense R') genome0 Dengue virus is transmitte% via the bite o5 )e%es mos=uitoes in particular !ae"ypti I !albopictus0 #n human %isease the cycle o5 transmission involves man<vector<man0 (he virus is present in bloo% in early acute phase only: generally 5or 1<5 %ays0 (he incubation perio% varies bet,een 8 to 10 %ays ,ith an average o5 !<2 %ays0 (here are 5our serotypes o5 %engue virus AD&'<1: D&'<: D&'<8 an% D&'<!B0 (hey areantigenically very similar to each other but %i55erent enough to elicit only transient partial cross<protection a5ter in5ection by each one o5 them0 $ost o5 the cases are reporte% among the urban population A10 J 70FB ,ith the highest inci%ence in the ,or4ing an% school going age group ,hich correlates ,ith the relatively high )e%es #n%e/ in construction sites: 5actories an% schools0 $y patient: ,ho is currently living in 3an%an #n%ah: a place ,hich has a high inci%ence o5 %engue in5ections be5ore an% is a 4no,n 5ogging area 5or 5e, times0 (hus: the inci%ence o5 having %engue in5ection is higher0 (here are a number o5 criteria 5or the clinical %iagnosis o5 %engue in5ection0 Ho,ever: not all the criteria nee% to be present at the same time0 10 high continuous 5ever o5 8 %ays or more 0 hea%ache: bac4ache an% retro<orbital pain 80 ab%ominal pain: vomiting: loose stools !0 petechial haemorrhage an%6or spontaneous blee%ing 50 rash J generalise% 5lushing6maculopapular 20 hepatomegaly 10 5all in platelet count that prece%es or occurs simultaneously ,ith a rise in the haematocrit 70 normal W>C or leu4openia ,ith relative lymphocytosis .0 normal &SR AK0mm 5irst hourB 100 shoc4 Dengue virus in5ection may present in 5our %i55erent clinical syn%romes: 10 Un%i55erentiate% 5ever 0 Classic %engue 5ever 3. #en$ue %aemorrha$ic &e'er (#%&) !0 Dengue Shoc4 Syn%rome LDSSM # ,ill 5ocus the %iscussion o5 my patient on %engue haemorrhagic 5ever Dengue Haemorrhagic Fever (DHF) (he critical stage is reache% at the en% o5 the 5ebrile phase o5 illnessG accompanying or shortly a5ter a rapi% %rop in temperature varying %egrees o5 circulatory %isturbances occurs0 (his phase rarely lasts longer than !7 hours0 (he 5ollo,ing must all be present: 10 Fever: or history o5 acute 5ever: lasting <1 %ays: occasionally biphasic0 0 Haemorrhagic ten%encies: evi%ence% by at least one o5 the 5ollo,ing: a0 a positive torni=uet test b0 petechiae: ecchymoses: or purpura c0 blee%ing 5rom the mucosa: gastrointestinal tract: in+ection sites or other locations 80 (hrombocytopenia A100:0006mm8 or lessB !0 &vi%ence o5 plasma lea4age %ue to increase% vascular permeability: mani5este% by at least one o5 the 5ollo,ing: a0 haemoconcentration Ae=ual to or greater than 0F above average 5or age: se/ an% populationB b0 a %rop in haematocrit 5ollo,ing volume replacement e=ual to or greater than 0F o5 haematocrit at presentation0 c0 signs o5 plasma lea4age evi%ence% by pleural e55usion: ascites an% hypoproteinemia0 *ther clinical mani5estations suggestive o5 DHF are a0 hepatomegaly ,hich may be ten%er b0 circulatory %isturbance #n my patient: there ,ere 5eatures o5 %engue in5ection0 She ha% high continuous 5ever o5 8 %ays or more: hea%ache: bac4ache an% retro<orbital pain: ab%ominal pain: vomiting: loose stools: 5all in platelet: initially leu4openia but ,ent to the normal W>C count in later stage0 (he reasons # %iagnose% her as having %engue haemorrhagic 5ever since there ,as 5ever ,hich laste% 5or about more than 10 %ays0 (here ,as also haemorrhagic ten%ency ,hich ,as per<vaginal blee%ing Aintermenstrual blee%ingB. She also ha% thrombocytopenia0 >esi%es: on e/amination an% /<ray: there ,as sign o5 plasma lea4age ,hich ,as signs o5 pleural e55usion0 *n e/amination: lung percussion ,as %ull at the lo,er -one on both si%es0 (he vocal 5remitus: air entry an% vocal resonance ,ere re%uce% at the lo,er -one on both si%es0 $oreover: there ,as a blunt costophrenic angle on chest /<ray0 3atient must meet all the criteria be5ore being hospitalise%0 (he criteria are continuous 5ever more than 8 %ays: lethargy: restlessness: generalise% 5lushing: e/cessive tire%ness: %ehy%rate%: ab%ominal %iscom5ort: haemorrhagic mani5estations: plasma lea4age an% evi%ence o5 circulatory 5ailure6shoc4 such as rapi% an% ,ea4 pulse: cool: mottle% or pale s4in or changes in mental status: restlessness an% lethargy0 #n %engue patient: ,e shoul% monitor the bloo% pressure: urine 5lo,: ,hite bloo% cells count an% platelets0 (he treatment 5or %engue in5ection: patient shoul% be starte% on intravenous 5lui% ,hich is 00.F so%ium chlori%e Anormal salineB L80< 50 ml64g6%ayM: DC9 supplement as re=uire%0 Ho,ever: caution is nee%e% in el%erly6car%iac %isease0 #n %iabetics patient only normal saline must be use%0 (he haematocrit level: vital signs an% urine output AhourlyB must be monitore% closely0 (he pleural e55usion occurs %uring the phase o5 plasma lea4age0 #t %ecreases thoracic compliance an% 5unctional resi%ual capacity lea%ing to hypo/emia an% increase% ,or4 o5 spontaneous breathing0 (hus: massive pleural e55usions can be prevente% by +u%icious replacement o5 intravascular volume0 $ost cases o5 blee%ing in DHF occur as a result o5 prolonge% shoc4 secon%ary to ina%e=uately correcte% plasma lea4age0 (here is a category o5 patients ,ith pre<e/isting peptic ulcers ,ho %evelop haemorrhage in the course o5 DF0 Ho,ever: there is no consensus on ho, these patients shoul% be treate%0