UNIVERSIDAD PRIVADA SAN JUAN BAUTISTA

FACULTAD DE CIENCIAS DE LA SALUD

ESCUELA PROFESIONAL DE MEDICINA HUMANA

Clinical case
INTEGRANTES
Agurto Fernández, Rosa Elena
Armas Perrigo, Diana Graciela
Cárdenas Yonjoy, Julia Ysabel
Chura Coaricona, Pedro Luis
García Velasquez, Marisol
Manchego Pinto, Juan Manuel
 Clinical case
A 13-year-old mixed-race male, a high school student, originally
from the urban area of ​Iquitos, weighing 46 kilos, was admitted
with an illness of approximately five days, with an insidious
onset and a progressive course characterized by unquantified
temperature rise, pain. muscle and joint, and headache.
On the second day of illness, he was treated
at a primary care health facility, receiving
symptomatic treatment (paracetamol), the
hematocrit was 35%, and the thick film and
smear test were negative. The fever increased
in intensity on the third day of illness; adding
loss of appetite, nausea and abundant
vomiting with bloody content; Disseminated
petechiae and finally moderate abdominal
pain, so he went to the emergency service of
the Loreto Regional Hospital, and was
hospitalized.
Physical exam

The clinical examination showed HR: 80 x', RR: 28x', BP: 100/60
mm Hg and T: 37°C, the patient was in fair general condition,
good nutritional and hydrated status, petechiae distributed
throughout the body. The lower limbs predominated and the
abdomen was distended with diffuse pain on superficial and
deep palpation, air fluid sounds present and Glasgow at 15. The
rest of the examination was normal.
Auxiliary exams

Ancillary tests on admission showed ESR 2 mm/hour, hematocrit

58%, platelets 170,000 x mm3, and white blood cell count and
count 11,200 with 22% lymphocytes.
48 hours after admission, the patient presented thrombocytopenia
with the presence of macroplatelets in the smear, reaching 33,000
x mm3, the leukocyte count was 4,000 x mm3 with 46%
lymphocytes and 40% neutrophils, sodium 140 mmol/L. , potassium:
3.5 mmol/L, chlorine: 112 mmol/L, normal urine test and arterial
blood gases pH 7.47; PO2: 78 mm Hg, PCO2: 33.7 mm Hg, HCO3
-: 24.6 mmol/L, Sat 96%
Diagnosis

The NS1 Ag detection test was performed and the result was
positive for dengue, serotype 3.

Treatment

The patient received intravenous hydration with 0.9% saline

solution, his general condition was fair, his appetite gradually
recovered, and the nausea, vomiting, and abdominal pain
subsided. The highest temperature recorded was 38.4º C, blood
pressure was maintained between 90/60 and 80/40 mm Hg and
urinary volume was normal.
Evolution

The patient progressed favorably, the tests were performed again:

blood count had leukocytes at 8,000 x mm3 with 56% lymphocytes,
hematocrit at 43% and platelets at 178,000 x mm3, so he was
discharged.
Thank you