CASE 1

CALXINA LUISA
JIVANANTHINI
 CHIEF COMPLAINT
• A 46 years old man known diabetes for 5 years presents with
history of fever associated with chills and rigors. He also
complained of left hypochondrial pain for 2 weeks

• What further history would you ask?

 HISTORY OF PRESENTING
ILLNESS
Mr A, a 46 year old gentleman with underlying diabetes mellitus for 5 years was
apparently well until 2 weeks ago when he developed abdominal pain.
Regarding the abdominal pain it is located at the left upper quadrant and is stabbing
in nature. He also noticed the pain while walking to the kitchen from the hall. The pain is
same throughout the day and progressively worsening (Initially pain score 3/10 and 4
days ago 7/10 and currently 9/10). The pain is radiated to the left shoulder. This is his
first episode and there is no aggravating factors however the pain is slightly reduced
upon leaning forward while compressing the pain site. He also complains of having early
satiety (feeling full upon eating small amount or not eating at all) for the past 5 days.
The pain was associated with nausea and vomiting which lasted for 1 week which
was progressively worsening (Initially the vomit is once a day then increase in frequency
2 days later to 3-4 times a day). It was a non projectile vomiting and not associated with
meal. Initially he vomited almost half a cup which increased to three quarter of a cup
and the contents depends on what he consumed (fluid/food particles).
 Otherwise he denies experiencing diarrhea, constipation, heartburn sensation,
yellowish discolouration of skin or eyes noticed, no history of trauma(especially to
abdomen), no loss of weight or appetite. He also denies any coagulation disorder or
easy bruising, bleeding gums/mucosa or nose bleed.
Mr A also had a history of fever. Regarding the fever it was presented together
with the abdominal pain 2 weeks ago and resolved 2 days ago. The fever was
described to be gradual in onset and intermittent in nature. There had been no
recorded temperature at home. His fever was associated with malaise, lethargy,
headache, chills and rigors. This condition has affected his daily activity ad he requires
frequent rest. There is no aggravating factor for the fever and is relieved with
paracetamol.
Regarding the headache, it is a mild frontal non-radiating headache and he gave a
pain score of 5/10. He took paracetamol which relieved the headache.
Otherwise there was no cough, sore throat, night sweats, breathlessness, nasal
discharge, joint pain or muscle pain, no profuse sweating, rash, no burning sensation
upon urination and no blood in urine, no discharge from genital region or itchiness,
and no loin pain. He denies noticing any mass or swelling.
 Patient did not seek medical attention.
He went for a trip to Sabah with his friends 1 week before the onset of the
symptoms. His trip itinerary included jungle trekking and camping at the jungle.
He claimed one of his friend also experienced fever and body ache but he did not
know further information. He did not receive any malaria prophylaxis or
consulted a doctor before travelling.
Patient has no history of sick contact, no one in the family/neighbourhood
experience similar symptoms.
He is married and is sexually active with only 1 partner.
SYSTEMIC REVIEW
General No sleeping disturbance
No excessive thirst

Gastrointestinal system No dysphagia

No haematemesis
No melena
No indigestion
Normal brown coloured stool and able to pass flatulence

Musculoskeletal system No joint pain, stiffness or swelling

No muscle pain or weakness
Genitourinary system Normal urine output and colour
Frequency according to fluid intake
No suprapubic pain
No swelling/ulcer at genital region
Endocrine No hot or cold intolerance
No hand trembling
No excessive hunger
Central nervous system No recent change in vision
Normal hear, smell and taste sense
No fainting
No dizziness or photophobia
No paraethesis (loss of sensation)
Respiratory system No cough
No wheezing
No stridor
No sputum production
No hemoptysis
Cardiovascular system No chest pain
No orthopnoea
No paroxysmal nocturnal dyspnea
No dyspnea on exertion
No leg swelling
 PAST MEDICAL/ MEDICATION
HISTORY
• Patient has diabetes mellitus for 5 years an is currently on
diet control and metformin. he goes for follow up at KK
Botanic 3 monthly. He is compliant to his medication and
follow up. He does not practice glucose home monitoring
and depends on his follow up. For his last follow up, his
blood glucose level was controlled.
• Otherwise no hypertension, dyslipidemia, gastritis and
never had admission for similar symptoms (tropical
diseases)
 PAST SURGICAL HISTORY/
PREVIOUS HOSPITALISATION
• Patient has never undergone any surgeries and has never
been hospitalized for any other medical condition before
this.
 DRUG HISTORY & ALLERGIES
• Patient was prescribed with metformin 500mg BD
• He has no known drug or food allergy
• He denied taking any traditional medication
• He consumed paracetamol for his headache
Family history
• Patient is the 2nd child out of three siblings and both of his parents
passed away due to old age
• Nobody in his family has any known medical illness
• No history of bleeding disorder, malignancies or sudden death in
his family
 SOCIAL HISTORY
• Mr A is married and blessed with 4 children.
• He stays in a single storey terrace house with his wife and children at a clean
neighbourhood (no rats/pests noticed )
• He is a businessman and has a flexible work schedule
• His house is a dengue prone area and the last fogging was ever done 6 months ago
at his neighborhood according to his knowledge.
• Otherwise there is no construction site or factories nearby to his house
• Patient denies smoking and consuming alcohol and or illicit drugs.
• He is following the suku-suku separuh diet.
PHYSICAL
EXAMINATION
 GENERAL EXAMINATION
• On general inspection, patient is consciously alert and is lying comfortably
on the bed at 45°. He is oriented to time, place and person. He was able to
speak in full sentences although he was experiencing pain. He appeared
slightly pale. Otherwise he is not jaundiced and no bluish discolouration.
He was medium built, well hydrated, well nourished and was not in
respiratory distress.
 VITAL SIGNS BMI
Blood 124/83 mmHg
pressure Height 165cm (1.65m)
Pulse 100 Weight 65kg
Respiratory 21 breaths/min BMI 23.88 (Normal)
rate
Temperature 37.8
Oxygen 98%
saturation
HANDS  Warm and dry to touch
 Has no tobacco stains
 Capillary refill time <2 seconds
 No rashes
 No peripheral cyanosis
 No finger clubbing
 No palmar erythema
 No osler nodes
 No janeway lesions
 No splinter haemorrhages
 No leukonychia
 No koilonychia
 No nail bed infarcts

NECK  Carotid pulse felt

 No raised jugular venous pressure
 No cervical, submandibular, sublingual, supraclavicular and infraclavicular
lymphadenopathy
 No thyroid enlargement
AXILLA  No acanthosis nigricans
 No loss of axillary hair
 No axillary lymphadenopathy

EYES  Presence of conjunctival pallor

 No jaundice and corneal arcus
 No xanthelasma

MOUTH & ORAL CAVITY  Moderate oral hygiene

 No gum bleeding
 No cavities
 No central cyanosis
 No yellowish discolouration of mucous membrane

LOWER LIMB  No pitting oedema

 No rashes
SYSTEMIC
EXAMINATION
 ABDOMINAL EXAMINATION
INSPECTION • Abdomen was flat and not distended
• Umbilicus is centrally located and inverted
• Abdomen moves along with respiration
• No surgical scar
• No striae
• No caput medusa
• No dilated veins, no visible peristalsis, no visible mass, no visible pulsation

PALPATION • On superficial palpation, the abdomen was soft and there was tenderness at left
hypochondriac region.
• On deep palpation, spleen tail was palpable 5 cm from the costal margin (firm swelling,
moves with respiration, unable to get above swelling)
• Otherwise no abnormal masses felt, no hepatomegaly (liver span was 10cm, regular, smooth,
well defined and tender with no pulsatility), both kidneys were not ballotable. There was no
rebound or guarding tenderness

PERCUSSION • Resonance over the abdomen but dullness over the enlarged spleen
• No shifting dullness
• Fluid thrill test is negative
AUSCULTATION • Normal gurgling bowel sound (Absent bowel sound at enlarged spleen)
• No aortic and renal bruits
 CARDIOVASCULAR
EXAMINATION
INSPECTION The chest move symmetrically with respiration
•
• No chest deformity
• No visible pulsation
• No surgical scar
• No dilated superficial veins
• No skin discolouration
PALPATION • All peripheral pulses are felt
• Radial pulse has normal volume, regular rhythm and normal
character with no radio radial or radio femoral delay
• Apex beat was felt at 5th intercostal space midclavicular line
• No thrills felt at all four cardiac regions
• No left parasternal heaves felt
AUSCULTATION • Normal S1 & S2 heard at all four cardiac regions
• No murmurs detected
• No bibasal crepitation posteriorly
 RESPIRATORY
INSPECTION
EXAMINATION
Normal chest shape
•
• Chest moves bilaterally along with respiration
• No pectus excavatum, pectus carinatum was appreciated
• No subcostal or intercostal recession
• No surgical scars
• No dilated veins
• No usage of accessory muscles
PALPATION • Trachea was centrally located
• Tracheal tug is 3 fingers
• Apex beat appreciated at 5th intercostal space midclavicular line
• Chest expansion was equal at all zones of both lungs
• Tactile vocal fremitus was equal at all zones of both lungs
PERCUSSION • Resonance at all zones of both lungs
• With cardiac and liver dullness
AUSCULTATION • Vesicular breath sounds heard at all zones of both lungs
• Equal air entry in both lungs
• No added sound heard
CENTRAL NERVOUS SYSTEM
EXAMINATION
 HIGHER MENTAL STATUS
• Patient was alert, conscious, and well oriented to time, place and
person.
• Patient has good memory and can speak in full sentences
 MOTOR EXAMINATION OF UPPER LIMBS

RIGHT LEFT

INSPECTION Normal posture Normal posture

No muscle wasting No muscle wasting
No muscle fasciculation No muscle fasciculation
No abnormal movements No abnormal movements

TONE Normal Normal

POWER 4/5 4/5

REFLEXES ++ ++
(Biceps, triceps, supinator
jerks)
COORDINATION Normal Normal
(Finger-nose test,
Rapid alternating test)
MOTOR EXAMINATION OF LOWER LIMBS

RIGHT LEFT

INSPECTION Normal posture Normal posture

No muscle wasting No muscle wasting
No muscle fasciculation No muscle fasciculation
No abnormal movements No abnormal movements

TONE Normal Normal

POWER 4/5 4/5

REFLEXES ++ (no clonus) ++ (no clonus)

(Knee and ankle jerks)
COORDINATION Normal Normal
(Heel shin test)
BABINSKI’S SIGN Negative Negative
 SENSORY EXAMINATION
SENSES UPPER LIMBS LOWER LIMBS
SIDE RIGHT LEFT RIGHT LEFT

Light touch Intact Intact Intact Intact

Pain Intact Intact Intact Intact

Vibration Intact Intact Intact Intact

Temperature - - - -

UPPER LIMBS LOWER LIMBS

Fine touch C5,C6,C7,C8,T1 intact Fine touch L2,L3,L4,L5,S1 intact

Pain C5,C6,C7,C8,T1 intact Pain L2,L3,L4,L5,S1 intact


NERVE
OLFACTORY NERVE (I)
OPTIC NERVE (II)
OCCULOMOTOR NERVE (III)
TROCHLEAR NERVE (IV)
TRIGEMINAL NERVE (V)
ABDUCENT NERVE (VI)
FACIAL NERVE (VII)
VESTIBULOCOCHLEAR NERVE (VIII)
GLOSSOPHARYNGEAL NERVE (IX)
VAGUS NERVE (X)
ACCESSORY NERVE (XI)
HYPOGLOSSAL NERVE (XII)
CRANIAL NERVE
EXAMINATION
COMMENTS
There was no loss of smell
Visual acuity for both eyes is 6/9
Patient could move his eye up, medially, down, and pupil size and reflexes were
normal
Patient could move his eyes down and in
Sensory: Touch & pain sensation equal on both sides
Motor: Masseter & temporalis muscle contract equally
Reflex: Normal corneal reflex and jaw jerk
Patient could move eyes laterally
No asymmetry, muscle power was normal
Patient’s hearing sense was normal
No displaced uvula, normal gag reflex
Patient can swallow normally
Patient can shrug his shoulders & able to move head left & right against resistance
Patient can protrude his tongue out and it does not deviate to either side, no wasting
of tongue
 SUMMARY
Mr A, a 46 years old gentleman with a known case of diabetes
mellitus type II for 5 years presented with left hypochondriac pain
for 2 weeks which was associated with nausea and vomiting. He
also experienced fever with chills and rigors that resolved 2 days
ago. He had history of travelling to malarial endemic region and
lives in a dengue prone area. His diabetes is under controlled.
Upon general examination, patient had conjunctival pallor. On
abdominal examination, he had tenderness at left hypochondriac
region upon superficial palpation and splenomegaly (5cm from the
costal margin) on deep palpation. On percussion, dullness over the
enlarged spleen. Absent bowel sound over the enlarged spleen.
Provisional diagnosis
• Uncomplicated malaria with splenomegaly
History • Resolved fever for 12 days (Intermitent) with chills and rigors
• Nausea, vomiting, headache, lethargy, malaise
• Left hypochondriac pain

Physical • General : conjunctival pallor

examination • Abdominal examination:
*Superficial palpation – tenderness ver left hypochondriac region
*Deep palpation - Splenomegaly
*Percussion - dullness over the enlarged spleen.
*Auscultation - absent bowel sound over the enlarged spleen

Risk factor • Travel to malaria endemic region

Differential diagnosis
Points supporting Points against
Dengue fever • Resolved fever 12 days (recovery stage) with chills and • Presence of splenomegaly (rare)
rigors
• Abdominal pain
• Nausea, vomiting, headache, lethargy, malaise
• Lives in dengue prone area
Leptospirosis • Resolved fever 12 days with chills and rigors • Intermittent fever ( Leptospirosis is
• Abdominal pain remittent)
• Nausea, vomiting, headache, lethargy, malaise • No exposure to stream water/water
activities
• Normal urine output
• No jaundice
• No arthralgia or myalgia
Typhoid fever • Resolved fever 12 days with chills and rigors • Intermittent fever (Typhoid is remittent
• Abdominal pain fever)
• Nausea, vomiting, headache, lethargy, malaise • No rose spot rash
• No rice water stool
• No hepatomegaly
• No lymphadenopathy
• Didn’t eat stall food recently
 Points supporting Points against
Acute • Left hypochondriac abdominal pain relieved by • Intermittent fever with chills and
pancreatitis leaning forward rigors
• Nausea, vomiting, headache, lethargy, malaise • Characteristic of abdominal pain
which is dull and radiates to the back
• Aggrevated by inspiration
• Does not consume alcohol
INVESTIGATIONS
Full blood count
Parameters Value Normal range Rationale
Red cell count 4.6 (4.5-6.5) )×/mm3
WBC 6.0 (4.00-11.00)×/mm3 To confirm infection

Hemoglobin 10.0 (13-18 ) g/dL To confirm and assess severity of

anemia (normocytic anemia)
Haematocrit 0.46 (0.40-0.54) To measure the red blood cells
Mean cell Hb 28.5 (27.0-33.0)pg
Mean cell volume 89.9 (78.0-98.0)fl

Platelets 400 (150-450) )×/L To rule out coagulopathy and

assess risk of DIC, rule out
thrombocytopenia
Blood culture and sensitivity is negative
• Ruled out typhoid fever, leptospirosis

To confirm malaria
• Blood Film for Malaria Parasite (BFMP)
• Polymerase Chain Reaction (PCR)
• Rapid Diagnostic Test (RDT)
• Liver function test - To rule out complication of infectious disease like hepatitis
*Assess function before administration of medications
• Renal profile - *To rule out acute kidney injury caused by infectious disease
*To rule out diabetic nephropathy
*To assess the function before administration of medications
• Coagulation profile To rule out any bleeding disorder, rule out hepatic dysfunction
• Serum amylase and lipase - To rule out pancreatitis
• Random or fasting blood glucose – To monitor glucose level
• Dengue combo test - Enzyme linked immunosorbent assay- IgG &IgM
• Transabdominal ct scan – to confirm site and size of spleen &to rule out
hepatomegaly
• ECG – To ensure normal ecg before administration of anti malarial drugs as it can
cause prolong QT interval which is can lead to lethal ventricular dysrhythmias
Management
Start antimalarial regime

• Riamet (1 tablet: 20mg artemether/120mg lumefantrine)

• A 3-day treatment schedule with a total of 6 doses is recommended.
• The patient should receive
• Day 1 : initial dose then 2nd dose 8 hours later
• Day 2 & Day 3 : 1 dose BD for the following 2 days.
• ≥35kg : 4 tablets per dose
• Artemisinin Combination Therapy (ACT)
• (Artesunate +Mefloquine) for 3 days

• OR

• Oral Chloroquine 10mg base/kg (max 600mg) stat

• Then, 5mg base/kg (max 300mg) 6 hours
• later,Day2 and Day3
 Non pharmacology
• Notify the district health office followed by disease notification form (Non
pharmacological)
• Advise on malaria prophylaxis – Mefloquine 2-3 weeks before travel
• Wearing clothing that minimises skin exposure to mosquitoes is advised
• Using of personal household protection measures, such as window screens,
repellents, insecticide treated materials, coils and vaporizers. These
measures must be observed during the day both inside and outside of the
home (e.g.: at work/school) because the primary mosquito vectors bites
throughout the day;
THANK YOU