case of a 25 year old female with fever

This is the case of a 25-year-old female, a resident of Nalgonda, and a homemaker, who presented to the outpatient department three days ago with chief complaints of 

- Generalised body pains since 9 days

- Bilateral knee ankle, metacarpophalangeal joint pains since 9 days

- Fever since 6 days 

- Headache since 6 days 

History of presenting Illness 

The patient was apparently asymptomatic 9 days ago when she developed generalised body aches which were sudden in onset, continuous, aggravated with the onset of fever and relieved on taking medication. 

9 days ago, the patient also had joint pains which were present bilaterally in the knee joints, the metacarpophalangeal joints, and the ankle joints. The Joint pains were of dull character, sudden in onset, continuous,  did not cause any functional impairment, and aggravated on the onset of fever. 

6 days ago, the patient developed a sudden onset, high-grade fever, associated with chills and rigour. According to the patient, the fever was in the range of 101-104 degrees Fahrenheit as measured on separate occasions, it was continuous with no diurnal variation (the patient denies any fever-free intervals during the day). The fever was relieved with medication. 

With the onset of fever 6 days ago, the patient also developed a headache which was sudden in onset, diffuse, throbbing in character, and continuous. It aggravated on rise in body temperature and was relieved on taking medication.

The headache was not associated with nausea, vomiting, retroorbital pain, aura, dizziness, or tinnitus. 

At this point, the patient visited an RMP who prescribed her paracetamol for the following symptoms which she consumed three times a day, it provided her with a few intervals of normal body temperature.

The patient was asked to get tested for dengue, the reports were positive for NS1 antigen, hence she came to our outpatient department. 

On day 1 of admission (three days ago), the patient developed 6 episodes of vomiting within 12 hours duration. The vomitus was non-projectile, non bile stained. There was absence of blood in the vomitus. There were no aggravated or relieving factors. The vomiting was not associated with neck rigidity, or chest or abdominal pain.

The patient also had four episodes of loose stool which were non-mucoid, non-blood stained. It was not associated with abdominal pain or tennismus.

On admission, Hess test positve

There is an absence of  sore throat, facial flushing , Blanchable macular rash(no islands of white in a sea of red)

Absence of neurological symptoms : Seizures , nuchal rigidity , jaundice , 

Past History 

The patient is not a known case of Diabetes mellitus type 2, Hypertension, Tuberculosis, Epilepsy, asthma, coronary artery disease 

6 Months ago, the patient underwent a cesarian section. 

There is no history of blood transfusions in the past. 

Family History 

There are no similar  complaints in the family 

Menstrual History - Para 1, Live 1 

 

Age at menarche - 13 years

regular cycles 5/30 days 

Not associated with pain or clots 

The patient is currently in lactational amenorrhoea 

 

Personal history 

Diet: Mixed 

Appetite; Reduced since the onset of fever 

Sleep: Adequate 

Bowel and bladder movements are regular and normal 

Addictions: None 

Allergies: No known allergies to food or drugs 

Community History

The patient suggests the presence of open fields and stored water surrounding her house and the presence of patients diagnosed with dengue fever in her neighbourhood. 

She gives a history of visiting a relative's place where there were presence of a large number of mosquitos 1 week before the onset of fever.

Daily routine 

- The patient wakes up at 8 am 

-consumes breakfast at 9 

- Does household chores throughout the day 

-lunch at 1 PM 

- Dinner at 8 pm 

General Examination 

The patient was conscious coherent, cooperative, and oriented to time place and person. 

The patient is moderately built and moderately nourished 

Vitals: 

Blood pressure 110/70 mm hg 

Temperature: Afebrile 

Pulse rate - 73 beats per minute, normal rhythm, volume ,character, no radio radial or radio femoral delay 

Respiratory rate 14 per minute 

Presence of petechiae on arm - after tourniquet test 

Absence of pallor, icterus, cyanosis , clubbing , lymphadenopathy, pedal edema 

- conjunctival injection 

Systemic examination 

Per abdomen 

Inspection : 

Umbilicus inverted, hernial orifices free, suprapubic transverse scar present, all quadrants move equally with respiration, scaphoid shape. 

Palpation : 

On superfcial and deep palpation 

Tenderness elicited in the right hypochondrium , epigastric region , left hypochondrium and hypogastric region 

Abdominal muscle tone normal 

No Guarding or rigidity 

Hepatomegaly seen 

Splenomegaly felt

No palpable masses 

Percussion 

- Tympanic note heard in all 9 segments of the abdomen 

Auscultation 

- Bowel sounds heard 

Cardiovascular system examination : 

S1, S2 Heard 

No thrills or murmurs 

Apex beat notes in the 5th intercoastal space 

Respiratory system examination 

Trachea central in position 

Bilateral air entry present 

Normal vesicular breath sounds were heard bilaterally in all areas 

Central nervous system 

 

Higher mental functions normal 

Cranial nerve examination: No abnormality detected 

Motor system 

- Bulk 

-Tone : Normal in both upper and lower limbs 

- Power- Normal power in both upper and lower limbs 

- Reflexes  bilateral 

    Knee jerk +2+2

    Ankle jerk +2+2

    Biceps reflex +2 +2

    Triceps reflex +2 +2

    Supinator +1+1

Gait: Normal 

Sensory system: Intact 

Cerebellum: Normal 

Provisional diagnosis: This is a case of a 25-year-old female with high-grade fever associated with chills and rigour, joint pain, Muscle aches, vomiting and loose stools 

 

suggestive of dengue 

Investigations 

- NS1 antigen test - Positive for dengue 

- Complete blood picture - 

Packed cell volume and platelet count is normal 

There is presence of leukopenia : involving granulocytes : Neutrophils 

- Blood sugar estimation 

- Electrocardiogram 

- Ultrasound abdomen 

- Liver function test 

Management

-Intravenous fluids - Normal saline at 100 ml/hour 

- Paracetamol 

-Capsule doxycycline 100 mg BD 

- Patient education 

- Vitals monitoring

- Fever chart ; no saddleback fever

Definitive diagnosis :  Dengue fever with thrombocytopenia

Criteria was taken under consideration from 

Signs for Probable dengue: Fever + Leukopenia, nausea vomiting arthralgia , myalgia positive torniquet test . 

Warning signs of dengue :

Abdominal pain, persistent vomiting, clinical fluid accumulation such as ascites or pleural effusion, mucosal bleeding, lethargy, liver enlargement greater than 2 cm, increase in hematocrit, and thrombocytopenia.

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Schaefer TJ, Panda PK, Wolford RW. Dengue Fever. [Updated 2022 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430732/