Clinicosocial Case Dengue

IDENTIFICATION DATA

Name : Nur Alya Maisarah Binti Suhaizi

Date of Birth : 10th September 2008

Age : 7 years old

Gender : Female

Religion : Islam

Race : Malay

Address : Puncak Alam

Registration no. : SB 00731170

Ward : 8C

Bed no. : 9

Date of Admission : 31/10/2015 11:50 PM

Date of Examination : 02/11/2015

Informant (Reliable) : Mashah Runi Binti Md Salin

CHIEF COMPLAINTS

1. Fever for 5 days.

2. Vomitting for 2 days

3. Diarrhea for 2 days

HISTORY OF PRESENTING ILLNESS

According to the mother, child was apparently well 5 days prior to admission. On the 1st day

of illness, mother notice that child had fever. Temperature was not recorded but mother

claimed that child was warmer than usual upon touch. Fever was associated with chills but

not rigors. At about 3 PM on the 2nd day of illness, mother had brought the child to a Proton

panel clinic, Klinik Ikhwan and child was prescribed with paracetamol. The fever did not

resolve despite administrating the prescribed medication. Child was again brought to the

same clinic. This time she was prescribed with antibiotics. Blood work was not done.

Mother waited two days, during which child was still having fever accompanied by lethargy

and loss of appetite. She was also vomiting and passing loose stool. Vomiting occurred

following oral consumption. Vomitus contained food particles and there was no blood

present. Stool was loose and yellowish with semi-solid and amounted about half (½) a cup

each passing without blood or mucus. Mother then took the child to the hospital.

Temperature recorded was 40°C and blood work revealed a significant drop in her platelet

count. Red spots on her abdomen were later discovered and child was admitted into the

hospital on the 5th day of illness.

During the duration of illness, child’s activities and feeding habits were affected. Mother

claimed that there was no recent history of travelling. However the child’s elder sister of 8

years old, were also having mild fever at the time with a slight decrease in her platelet count.

The sister was not admitted but is required to come for daily blood check.

SYSTEMIC REVIEW

1. General Patient was ill looking. No weight loss or pallor noticed.

2. Central Nervous Patient was irritable. No fits. No incidents of black outs or abnormal

movement.

3. Musculoskeletal Myalgia and athralgia present. No numbness.

4. Gastrointestinal No constipation.

5. Cardiovascular No edema or swelling. No bluish discoloration.

6. Respiratory No cough or flu. No rapid breathing. No in drawing of chest. No

abnormal sound heard during breathing.

7. Genitourinary No dysuria or polyuria, no changes to the volume or colour of urine

and no presence of blood.

8. Skin No blisters, bruises or abscesses.

9. Endocrine No temperature intolerance or polydipsia.

HISTORY OF PAST ILLNESS

Patient was previously admitted to Hospital Sungai Buloh 2 days after birth for one week due

to neonatal jaundice which improved with phototherapy.

There was no history of surgical intervention nor is there history of nebulisation or

transfusion required by the child.

BIRTH HISTORY

ANTENATAL

Mother claimed that she attended her antenatal check up routinely correspondent to the dates

and had received anti-Tetanus Toxoid (aTT) vaccination via intra-muscular (IM) injection.

Her blood was drawn for serology test, which included screening of Hep B, Hep C, Syphillis

and HIV, and the results were negative. Mother was diagnosed with Gestational Diabetes

Mellitus and was adviced to control her diet. Besides that she was not anaemic and did not

have Pregnancy Induced Hypertension (PIH). At the time, mother took folic acid and Obimin

(multivitamin) supplements. She did not drink alcohol, smoke or use recreational drugs.

Mother did not experienced any physical or emotional trauma, threatened miscarriage, fever

associated rashes, antepartum hemorrhage (bleeding or spotting), Urinary Tract Infection

(UTI), toxaemia or any exposure to radiation during her pregnancy.

NATAL

Child was delivered at the gestational age of 37 completed weeks at Hospital Sungai Buloh

via spontaneous vertex delivery after 2 hours in the labour room. There was no complication

of bradycardia, hypotension, respiratory depression or others during the labour.

POSTNATAL

Child cried vigorously immediately after birth. Child was born with birth weight of 2.2 kg,

without any gross congenital deformities or abnormalities. Child was fed colostrums within 2

hours and she passed urine and meconium within the 1st day of life. Child developed jaundice

on 2nd day of life which dissolved after 2 weeks. There was no cyanosis, respiratory distress,

congenital sepsis or meningitis, convulsion, skin rash or any other complications after birth.

Both mother and child were discharged after a week.

FEEDING & DIETARY HISTORY

PRELACTEAL FEEDING

No prelacteal feeding administered.

BREASTFEEDING

Mother breastfed the child exclusively for 6 month before the introduction of formula milk

and continued breastfeeding the child up till 2 years old.

COMPLEMENTARY FEEDING

After 6 months, mother began complementary feeding with formula milk. She started with

the brand Progress, 4 ounce of water mixed with 4 scoop of milk powder. Later child was

introduced to nestum.

CURRENT DIETARY INTAKE

Child now takes normal adult diet such as rice, biscuits and noodles.

IMMUNIZATION

Child’s immunization is up-to-date as per National Malaysia EPI schedule and no other

additional vaccines were given.

Age (months)

0 1 2 3 5 15 18

BCG √

Hep B √ √ √

DPT √ √ √

IPV √ √ √

Hib √ √ √

MMR √

DEVELOPMENTAL HISTORY

GROSS MOTOR

Patient is able to run and climb up and gets down stairs without support. Able to ride a

bicycle?

VISION & FINE MOTOR

Patient was able can write and draw with her right hand.

HEARING, SPEECH &LANGUAGEPatient can speak fluently in her local language. She

can also identify colours and able to spell.

SOCIAL, EMOTIONAL & BEHAVIOUR

Patient able to dress herself and mother mentioned that at home, she gets along with family

members and her siblings. At school she claims to have plenty of friends.

Mother claim patient is performing well in school and is able to keep up academically.

TREATMENT & ALLERGY HISTORY

Child was not on any medication or treatment and she has no known allergies to either food,

drugs, pollen or others.

FAMILY HISTORY

She is a child of a non-consanguinous marriage of 10 years with 3 other older siblings and 2

younger sisters. Mother claimed there is no history of asthma, cancer or other known disease

in the family on either the maternal or paternal side. No history of miscarriages.

SOCIOECONOMIC HISTORY

Father works in maintenance for Proton. Mother works as a teacher in an integrated school.

The gross monthly income of child’s parents is about RM 4000 and mother denied any

financial problems. Child lives with her parents, a brother and 3 sisters as well as a maid in a

double storey terrace house. The house is equipped with adequate basic amenities. The house

is not furnished with any thick carpets. They have no other pets beside an aquarium of

assorted fishes which is maintained by the father. The house is not located in an industrial or

crowded area. There are however several construction sites nearby. No lake or river is seen in

the area. Several known cases of dengue from the area have been reported including one case

of mortality. None of the members of the household either smokes or drinks. During the day,

child attends school from morning where breakfast and lunch is provided until 4.30 PM.

SUMMARY

My patient, AlyaMaisarah, a 7 years old Malay girl, presented with fever for 5 days and

vomiting and diarrhea for 2 days. She lives in a dengue prone area with no history of

travelling. Red spots noticed upon admission. Patient blood work shows that she has low

platelet count.

PHYSICAL EXAMINATION

General inspection

Child was conscious, comfortable and lying supine on the bed prompted by one pillow. She

was not agitated and there were no signs of respiratory distress. There was no dysmorphic

features seen. Hydration status is fair (skin retracted immediately) and no sunken eyes. IV

branula is seen on his right hand dorsum.

Vital signs

Temperature: 36.8°C (afebrile)

Pulse rate : 100 beats/min (normal for age) with regular rhythm and good volume

Respiratory rate: 24 breaths/min (normal for age)

Blood pressure: 113/65 mmHg (normal for age)

SPO2 %: 97% in room temperature

Anthropometry measurements

Height : 134 cm ( between 97th to 99th percentile)

Weight : 27 kg ( between 85th to 95th percentile)

BMI : 15 kg/m² ( between 50th to 75th percentile) (healthy)

Head to Toe Examination

Head –

No dysmorphism or abnormalities seen.

Eyes –

No jaundice on sclera and lower palpebral conjunctiva has no pallor. There was no periorbital

edema, no eye discharge, no sunken eyes or subconjunctival haemorrhage seen.

Ears –

Moderate ear wax seen bilaterally but there was no discharge.

Nose –

Nasal bridge appears normal and nasal flaring was absent. Any nasal deformities or nasal

discharge were not seen either.

Neck –

No elevated jugular venous pressure (JVP). No thyroid swelling or lumps palpable.

Oral –

Lips: moist, no cleft seen, no bluish discoloration (central cyanosis), no angular stomatitis, no

lesion or ulcer in inner surface of lips.

Gums: no gum swelling or bleed, no lesion or ulcer seen and there was no hyperplasia.

Teeth: no signs of teeth decay or carries.

Tongue: not dry or coated, no cyanosis, not enlarge or inflamed

Oral mucosa: pink and moist, no ulcers or lesions seen.

Tonsils : not enlarge, inflame or red in colour

Pharynx : not enlarge, inflame or red in colour

Overall oral hygiene is good and oral cavity is healthy.

Hands –

Palms were warm and dry. Palm was not pale, capillary filling time was less than 2 seconds,

there was no palmar erythema. The fingernails had no clubbing, no splinter haemorrhage, no

peripheral cyanosis, no koilonychias or leukonychia. There was also no janeway lesion and

no osler nodes seen.

Skin –

Presence of BCG scar on left deltoid muscle. There was desquamation of skin, honey crusted

lesions, hypopigmented scars and scab formations seen bilaterally on her hands, arms and

legs. Some erythematous macules were also noted. A few of the lesion present on her legs

were bleeding upon scratching and some were noticed to discharge transparent fluid.

Lower limb –

There was no ankle (pitting) edema or swelling noted. No cyanosis and no clubbing of toe

nails. Sole of feet were not pale or jaundiced. There were no visible deformities seen.

Back –

There was no spina bifida, no sacral edema, no surgical scars or deviation of vertebrae noted.

Lymph nodes – all group of lymph nodes was not palpable.

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection :

- No chest deformity, no visible pulsation and no surgical scar

- There was no precordial bulging and no dilated veins.

Palpation :

- Apex beat felt at 5thintercostals space, at midclavicular line

- No parasternal heaves or palpable thrills felt

- No radio- radial delay, no radio- femoral delay and no collapsing pulse

Auscultation :

- 1st and 2nd heart sound heard at all 4 areas.

- Normal heart sound and no murmur or thrills heard.

- No other additional sounds heard.

RESPIRATORY SYSTEM

Inspection :

- There was no surgical scar, no dilated veins, no visible pulsation

- She was breathing normally without using accessory muscle.

- No deformity seen on chest and chest is not hyperinflated.

- There was no subcostal or intercostal recession seen.

Palpation :

- Trachea is not deviated and is centrally located

- Vocal fremitus is equal and bilaterally heard at all three zones

- Chest expansion is bilaterally equal and symmetrical.

Percussion :

- Resonant sound was heard bilaterally at all sites of percussion.

Auscultation :

- Air entry is equal and bilateral on both lungs

- Vesicular breath sound heard with normal intensity

- No added sound heard

ABDOMEN EXAMINATION

Inspection:

- Abdomen mildly scaphoid in shape and was not distended

- All nine quadrants moves symmetrically with respiration.

- Umbilicus was centrally located and inverted

- There were no dilated veins.

- There were no surgical scars.

- There were no hypopigmentation or rashes seen.

Percussion

- Resonant (tympanic) on all 9 quadrant

- No shifting dullness and no fluid thrills

Palpation

- Abdomen was soft and non- tender.

- No abdominal masses were felt during superficial and deep palpation.

- Kidney was not ballotable.

- Liver and spleen were not palpable.

Auscultation

- Normal bowel sound heard with normal intensity.

- No bruits were heard.

CENTRAL NERVOUS SYSTEM AND MUSCULOSKELETAL SYSTEM

Upper limbs

Right Left

Muscle tone Normal Normal

Muscle power 5/5 5/5

Muscle reflex :

- Biceps

- Triceps

- Supinator

++

++

++

++

++

++

Sensation Normal Normal

coordination Normal Normal

Lower limbs

Right Left

Muscle tone Normal Normal

Muscle power 5/5 5/5

Muscle reflex:

- Knee jerk

- Plantar

++

++

++

++

- Babinski’s Negative Negative

Sensation Normal Normal

Coordination Normal Normal

Meningeal irritation sign:

- Neck rigidity : absent

- Kernig’s sign : absent

- Brudzinski’s sign : absent

INVESTIGATIONS(31/10/2015)

Full blood count

Results Normal ranges

White blood cell 3.03X10^9/L (Low) 4.5-13.5X10^9/L

Red blood cell 5.02X10^12/L 3.9-5.6X10^12/L

Haemoglobin 13.4g/dL 11.5-14.5g/dL

Hematocrit 39.1% 37-45%

Mean cell volume 77.8fl 76-96fl

Mean cell

haemoglobin

26.7pg (Low) 27-31pg

Platelet 137X10^9/L

(abnormal)

150-400X10^9/L

Full blood count

White blood cell Results Normal ranges

% Neutrophil 67.9% 40-75%

%Lymphocyte 26.7% 20-40%

%Monocyte 1.6% (Low) 2-10%

%Eosinophil 0.6% (Low) 1-6%

%Basophil 0.4% <1%

Renal profile


Sodium 134mmol/L (Low) 135-150mmol/L

Potassium 3.6mmol/L 3.5-5mmol/L

Chloride 105mmol/L 98-107mmol/L

Creatinine 58.9mmol/L 44-88mmpl/L

Urea 4.7mmol/L 1.7-6.4mmol/L

Liver function test


Globulin 34g/L (High) 2.0-3.5g/dL

Globulin albumin

ratio

1.11 0.8-2.0

Total bilirubin <1.8µmol/L (Low) 0.3-1.9mg/dL

Alanine transaminase 27U/L 7-55U/L

Albumin 38g/L 3.5-5.0 g/dL

Alkaline phosphatase 162U/L (High) 45-115U/L

No result for coagulation test profile

Cardiac Enzyme


Aspartate

transaminase

57IU/L (High) 5-35IU/L

Lactate

dehydrogenase

453IU/L (High) 140-280IU/L

Creatine kinase 163IU/L 25-195Iu/L

Dengue serology NS-1 antigen combo kit: Positive

Dengue gM negative

Venous blood gases:

pH: 7.40 (normal)

HCO3: 23.6mEq/L (normal)

Lactic acid: 1.5

MANAGEMENT

Plan by the hospital:

- Fluids

a) IV fluid normal saline for 27kg (135cc/H)

At 2am, reduce IVD to 108cc/H


b) Encourage orally

- Medication

Syrup PCM 400mg 6 hourly/PRN (15mg/kg)

- Ventilation

Room air.

- Monitoring

Temperature, fluid intake and urine output.

TREATMENT

Plan by the hospital:

Fluids

a) IV fluid normal saline for 27kg (135cc/H)



b) Encourage orally

Medication

Syrup PCM 400mg 6 hourly/PRN (15mg/kg)

Ventilation

RA

Monitor

Temperature, fluid intake and urine output.

PERSONAL ASSETS AND SOCIOECONOMIC STATUS

Our patient, NurAlyaMaisarah, a 7 year old Muslim girl together with 8 other occupants,

lives in a middle cost double storey terrace house located in PuncakAlam, Selangor. She lives

with both her parents, her 5 siblings whom include three sisters and two brothers as well as a

maid.

They bought the house in the year 2005 and are currently paying an instalment of RM500

monthly. The house has 4 bedrooms, 3 upstairs and 1 downstairs, 3 bathrooms, one

downstairs and two including a shared bathroom upstairs. They also have a family room

located upstairs and the living room downstairs which includes the dining room as well as the

place where the family carries out their daily prayers. There are enough rooms in the house to

compensate for the number of occupants. Alya shares a room with her two other sisters, while

her parents and her youngest sister aged 1 year old sleeps in the master bedroom. Her two

elder brothers who are currently attending boarding school shares a room together and the

maid lives in the room downstairs.

As for the financial support, both Alya’s parents are the breadwinnerof the family. Her

father works in Proton as part of the maintenance section while her mother works as a teacher

in an integrated school nearby. The total monthly income is estimated to be around RM4000

and the mother claims to have no financial problems. The family does not receive any

subsidies from the government however medical services and school fees are covered.

Medical services are covered by her father’s company while they receive subsidies by Pusat

Zakat Selangor for schooling fees.

Other assets of the household includes:

-Two televisions (Brand HITACHI and SINGER).

-Chery Easter 2.0 ES MPV (Monthly instalments of RM 850)

-7 seater Toyota Avanza (No more monthly instalments)

-A Yamaha motorcycle

-One LG refrigerator

-One Panasonic washing machine

-The family does not have a landline phone but they have 5 mobile phones (4 branded

Samsung and one Nokia) and a Samsung tab (Monthly the family pays a bill of RM200 as

they have subscribed to the family package)

-1 Maid (Monthly instalments of RM600)

PERSONAL ASSETS

ITEMS QUANTITY

HOUSE

- Middle Cost double storey terrace house 1

VEHICLES

-7 seater Toyota Avanza

-Chery Easter 2.0 ES MPV

-Yamaha motorcycle

1

1

1

PHONE

-Land line

- Nokia mobile phone

- Samsung mobile phones

-Tab

-

1

4

1

LIVING ROOM

-3 sofa seater

-A long wooden chair

-A set of two wooden chairs and a rounded

console table

-A dining table with 6 chairs

-Television ( SINGER)

-Showcase table

1

1

1

1

1

1

KITCHEN

-Rice cooker

-Cooking stove

-Gas cylinder

-Refrigerator

1

1

2

1

BEDROOM 1 (DOWNSTAIRS)

-Double size mattress

-Bedframe

-Plastic cupboard

1

1

1

BEDROOM 2 (UPSTAIRS-ALYA’S ROOM)

-Double size mattress without a bedframe

-A wardrobe

-Ironing board

1

1

1

BEDROOM 3 (UPSTAIRS-MASTERBED

ROOM)

-Double sized mattress

-Bedframe

-Baby cradle

-A cupboard

1

1

1

1

BEDROOM 4 (UPSTAIRS- BOY’S ROOM)

-A single sized mattress

-Bedframe

1

1

FAMILY ROOM AND LAUNDRY ROOM

-Television (HITACHI)

-Washing machine

-Rails to hang clothes

-Speakers

1

1

1

1

TOILET 1 (DOWNSTAIRS)

-Pail

-Water hose

1

1

BATHROOM 1(UPSTAIRS –ALYA’S

ROOM)

-Pail

-Water hose

1

1

BATHROOM (UPSTAIRS- SHARED

TOILET)

-Pail

-Water hose

1

1

ANIMALS

-Fishes

GARAGE

-Aquarium

-Water Filter

1

1

SANITATION STATUS AND HOUSING STANDARD

FLOOR PLAN OF THE HOUSE (DOWNSTAIRS)

FLOOR PLAN OF THE HOUSE (UPSTAIRS)

The house in a middle cost double storey house. It is located in PuncakAlam and there is

access to public transport facilities particularly busses.

Patient’s family gets their water supply from SYABAS as evident by a water storage tank

nearby their house. The water supply as described by patient’s mother has to be constantly

filtered as there is a strong odour of chlorine occasionally. She also describes the water to be

yellow in colour sometimes .Otherwise, water pressure and flow rate is adequate and there

are no shortages of water in their housing area. The air ventilation in their house is good as

evident by window panes present in almost all the rooms in their house as well as ceiling

fans. Their electrical supply is from Tenaga Nasional and there are no shortages of electrical

supply. Patient’s house is cleaned everyday by the maid.

Solid waste (Garbage) is disposed in the blue bin located in front of patient’s house.

The garbage collector truck comes twice in a week.

Two doors away from patient’s house is a house that is undergoing renovation. Patient’s

mother believes that the house could possibly be the site of possible vector breeding. To add

to that, many blue bins in front of alya’s neighbour house has accumulation of water in it,

resorting to a probably vector breeding area.Otherwise, patient’s family ensures that the

garage and backyards are cleaned regularly to avoid breeding of Aedes mosquitoes. She also

inserts guppy fishes in her pots of flowers to prevent mosquito breeding.

LIVING ROOM

The living room has a marble floor with the presence of two linen carpets located in two

locations respectively. The wall is painted with multiple colours (pink and green) as well as

wallpapers are also attached. Overall, there is good air ventilation as evidence by the presence

of two window pane and a sliding glass door. There are also 3 ceiling fans in the living room.

There is a 3 sofa seater present with a long wooden chair. A rounded console table with two

wooden chairs is also present.The dining table is located in the living room. A Singer flat

screen TV is present. The overall cleanliness of the living room is good.

KITCHEN

The floor is clean and made up of tiles. The wall is painted. Overall, the kitchen consists of a

refrigerator, a gas stove, a sink with good water supply in terms of flow rate and pressure.

There are also two small rectangular tables with 4 plastic chairs present. The ventilation is

good as evidenced by the presence of 4 window panes and the overall sanitation is good.

GARAGE

This is the front yard of the house. The cars are usually parked outside. As for the yard, a play

area is present for the children. There is also a table present with a few plastic chairs and a

wooden chair. The aquarium is located outside and is cleaned regularly. The floor is tiled and

the sanitation is good.

BEDROOM ONE WITH TOILET ONE

The above shows the bedroom downstairs in which the maid sleeps it with its accompanied

washroom. The room consists of a double sized mattress with a bedframe and a stack of

pillows present. The floor is made up of tiles and certain dry groceries from the kitchen are

also kept in the room. As for the toilet, a pail and water hose is present. Overall sanitation is

good. As for the ventilation however, the room lacks a ceiling and a table fan.

BEDROOM TWO WITH BATHROOM TWO

Alya’s and her two sisters’ sleeps in bedroom 2 located upstairs. The room consists of a

double bed mattress with stacks of pillows, however without a bedframe. The floor is made

up of wooden planks and appears to be very clean. Air ventilation is good due to presence of

window panes and a ceiling fan. An ironing board is seen with a small wardrobe. The

bathroom contains a water hose and overall sanitation is good.

BEDROOM 3

The master bedroom consists of a double bed mattress with its associated stacks of pillows

and bed sheets. A baby cradle is also seen for Alya’s youngest sister to sleep in. The wall is

painted blue and orange. Overall the sanitation is good and the ventilation is also good as

evident by a ceiling fan.

BEDROOM 4

Alya’s two elder brothers (whom are currently attending boarding school) sleep in bedroom 4

on a single bed mattress without a bedframe. The number of pillows is adequate. The walls

are painted and many clothes are seen to be hanging in the room. Overall sanitation is good.

SHARED BATHROOM

This bathroom is used by both Alya’s parents and Alya’s brothers. A pail is seen and the

overall sanitation is good.

FAMILY HALL AND LAUNDRY AREA

In the room, a television with the set of speakers is seen. However, the television is not in use

anymore. Numerous rails to hang clothes are present as the washing machine is present in the

family hall. Air ventilation is good due to presence of numerous window panes. Overall

sanitation is good.

BACKYARD

There is a pile of woods present with a two vases and an empty vase present. The flow is the

drain is good and not stagnant.

IN REFERANCE TO POTENTIAL VECTOR BREEDING SITE

A house undergoing renovation just two doors away from Alya’s house was observed and

could be a probably Aedes mosquito breeding site.

In Alya’s garage, a vase with water is present. However, in order to prevent the breeding of

Aedes mosquitoes, a guppy fish is inserted by Alya’s parents.

A container with accumulation of water was noted in the backyard of the neighboring houses.

A black bin with accumulation of water on the cover was observed in the neighborhood.

A GROUP PHOTO WITH ALYA’S FAMILY BEFORE DEPARTING BACK TO

SHAH ALAM

DIET HISTORY

Alya’s breakfast and lunch are served by the school she’s in. For breakfast, she usually has a

plate of fried rice or nasilemak and a cup of Milo or Horlicks. For lunch , she has rice with a

vegetable dish (any and every kind) and a fish or chicken or egg dish.For tea-time, she

usually has kueh lapis or a slice of fruit cake with a cup of Milo. As for dinner , she has it at

home and it is prepared by the maid , and usually constitutes rice , vegetables and fish or

chicken dish.

Her lunch and dinner meals usually constitute one portion of rice , one portion of non-vege

like fish or chicken and one portion of vegetables. She has no dislikes and eats every kind of

food. She has no known food allergy towards any form of food.

NUTRITIONAL STATUS

Food Serving/Portion Calories Carbohydrate Total Fat Protein

Breakfast

NasiLemak 1 bungkus

(packet)

552 kcal 58.2g 13.1g 9.7g

Milo 1 cup 84kcal 14g 2g 0g

Lunch

Rice (plain) 1 portion 260kcal 23g 0.9g 2.6g

Vegetable

dish

(Eggplant

sambal)

1 portion 36kcal 5g 1.9g 13g

Pan-fried fish 1 piece 251kcal 25g 9g 23g

Tea-time

Steamed kueh

lapis

1 slice 137kcal 0.3g 0.3g 0.1g

Milo 1cup 84kcal 14g 2g 0g

Dinner

Rice(plain) 1 portion 260kcal 23g 0.9g 2.6g

Stewed

vegetables

1 portion 34kcal 4g 1.0g 11g

Fried chicked

dish

1 piece 246kcal 1.8g 12g 27g

Total 1944kcal 168.3g 61.1g 89g

HEALTH AND MEDICAL SERVICE UTILIZATION

Alya and her whole family receives free medical services from KlinikIkhwan , as her father’s

work place is a panel under the clinic. KlinikIkhwan is located .As none of her family

members suffer from any form of chronic illness , they usually only have to visit the clinic

when one of them is down with cough or cold which are the usual complaints.

Alya’s youngest sister ,Shifa , aged 15 months , still requires immunization and for that

purpose , she is brought to KlinikDesa ,Bandar PuncakAlam, FasaDua located less than 10

km from their home.

The nearest functioning clinic is KlinikKesihatan which is located less than 1 kilometer from

their house .

The nearest hospital is Hospital Sungai Buloh which is located 27 kilometers from their home

and takes about 25 minutes to get there by car.

PSYCHOLOGICAL HISTORY AND EFFECT OF ILLNESS ON PATIENT AND

FAMILY

ON THE PATIENT

According to the patient’s mother, ever since she had fever that lasted for 5 days, her food

consumption was reduced and she did not drink a lot of water. Furthermore, she experienced

vomiting and diarrhea which makes her feel exhausted and restless. She did not show any

interest in engaging in physical activities and talked very less because she was tired. Because

of her illness, she was absent from school for 5 days, but she claims that she is not behind in

all her homework.

ON THE FAMILY

During the period of patient’s illness, both her parents had to take 2 days leave from work to

take care of her at Hospital Sungai Buloh and her other siblings at home. The leave that they

took was from their annual work leave and it does not affect their monthly income.

Because they had a maid working to take care of the house, her needs of her other siblings

were also fulfilled. Patient’s illness and the increasing amount of Dengue Fever occurring in

the neighbourhood, made the family much more aware of the danger this disease, thus they

had taken the first step of precaution to eliminate all possible containers that could hold

stagnant water and made sure to spray the house with mosquito repellent during dusk and

dawn.

DIAGRAM SHOWS WEB OF CAUSATION OF DENGUE FEVER FOR

As in the diagram, there are 5 possible causes that could lead to Alya getting infected with

dengue virus. The 5 causes are lack of awareness, aedes breeding site, going out during aedes

active period, living in a dengue prone area, and having low immunity.

The main probable reason for her to get infected is by living in a dengue prone area. This is

evidenced by recent and regular fogging done by the Ministry of Health and there was a

banner stated that the housing area is a dengue red zone. During our visit to her housing area,

there was a lot of stagnant water. One of them was in an exposed rubbish bin with no lid on at

the neighbouring house. Then, there were empty vases and buckets which are able to leave

water residues and thus, leading to aedes breeding site.

Some of the causes are co-related to one another. For example, stagnant water in the pail can

turn into mosquito breeding side and this will lead to dengue fever at the whole area. Lack of

awareness is also one of the main reason the patient get infected. For example, if the patient's

parents and family members have enough knowledge and know how to apply it, they

wouldn’t let her play outside the house during aedes active period.

Furthermore, child of a young age as hers still are having low immunity, predisposes her to

have higher chances in getting infected. Thus, her body couldn't withstand the virus leading

to dengue fever.

Epidemiology

Dengue is vector-borne viral disease that is fast emerging pandemic-prone in many parts of

the world. Dengue has been widely distributed in tropical and subtropical countries,

flourishes in urban and suburban areas and the countryside.

Severe dengue (previously known as dengue haemorrhagic fever) was first recognized in the

1950s during dengue epidemics in the Philippines and Thailand. Today the incidence of

dengue has increased by 3-folds and has become a leading cause of hospitalization and death

among children and adults in these regions. By the late 1990s, Dengue was the most

important mosquito-borne disease affecting humans after Malaria, with around 40 million

cases of Dengue Fever. In 2012, was classified as ‘ the most important mosquito- borne viral

disease in the world’ with estimation of 2.5 billion people at risk living in over 100 endemic

countries and up to 50 million infections occurring annually with 500,00 cases of Dengue

hemorrhagic fever and 22,000 deaths mainly among children.

EPIDEMIOLOGICAL TRIAD

Aedesmosquito act as the vector, human as a host, dengue virus as the agent and the

temperature/ tropical country as the environment factor.

Aedesaegypti mosquito lives in urban habitats and breeds mostly in man-made containers.

Unlike other mosquitoes Ae.aegypti is a day-time feeder; its peak biting periods are early in

the morning and in the evening before dusk. Female Aedesaegypti bites multiple people

during each feeding period. Aedesalbopictus, a secondary dengue vector in Asia,largely due

to the international trade in used tyres (a breeding habitat) and other goods. Aedesalbopictus

is highly adaptive and, therefore, can survive in cooler temperate regions of Europe. Its

spread is due to its tolerance to temperatures below freezing, hibernation, and ability to

shelter in microhabitats. Infected humans are the main carriers and multipliers of the virus,

and serving as a source of the virus for uninfected mosquitoes. The eggs change into larvae in

2-3 days, and transform into pupae after 4-5 days. Finally turn into adult mosquito after 1-2

days(mosquito life cycle is 8 days). Dengue virus has different serotypes there are DEN-1,

DEN-2, DEN-3, and DEN-4. DEN-2 serotype is the most virulent and DEN-4 is rare.

Changes in virulence in some serotypes (DEN-2 and DEN-3) is related to increase occurrence

of dengue hemorrhagic fever. Factors that affect host(human) are individual immunity,

genetic differences and herd immunity. Factors that affect environment are

tropical/subtropical countries has optimal temperature for breeding of mosquito and

VECTOR

AGENT

ENVIRONMENTHOST

transmission of virus. Also, rapid urbanization and cleanliness of the environment also

greatly contributed.

Geographical distribution

Geographical expansion of the mosquito has been aided by international commercial trade

particularly in used tyres. Increased air travel and breakdown of vector control measures have

also contributed greatly to the global burden of Dengue and Dengue Hemorrhagic Fever.

The recent trend for Dengue is increasing in Cambodia, Lao People’s Democratic Republic,

Malaysia and Singapore. Compared to 2013, Malaysia was the only country of these four

where 2014, was substantially higher compared to same period in 2013.

In Malaysia, among all states, the highest incidence is in Selangor which accounts 4,894 cases and 5 deaths in 2014. As compared to previous year 2013, 1,154 cases and 1 death. It

shows marked increase in trend of dengue in most of the states in 2014.

Global burden of dengue

The incidence of dengue has grown dramatically around the world in recent decades. One

recent estimate indicates 390 million dengue infections per year (95% credible interval 284–

528 million),

In 2010, nearly 2.4 million cases were reported. Although the full global burden of the

disease is uncertain, the initiation of activities to record all dengue cases partly explains the

sharp increase in the number of cases reported in recent years.

Other features of the disease include its epidemiological patterns, including hyper-endemicity

of multiple dengue virus serotypes in many countries and the alarming impact on both human

health and the global and national economies. The geographical areas in which dengue

transmission occurs have expanded in recent years and all four dengue virus serotypes (DEN-

1 to DEN-4) are all now circulating in Asia, Africa and the Americas as compared to 20-30

years ago, in America and Africa region, only two serotypes can be found(DEN-1 and DEN-

2). Studies been conducted to understand the evolutionary relationships.

With over 2.5 billion people, which is over 40% of the world's population now at risk from

dengue it is only right that economic expenditure on the disease would be on a high. More

than 100 countries from the regions of Africa, the Americas, the Eastern Mediterranean, the

South-east Asia and the Western Pacific are mainly affected (tropical countries). In endemic

countries in Asia and the Americas, the burden of dengue is approximately 1,300 disability-

adjusted life years (DALYs) per million population.

The direct economic impact of dengue in the two continents( South East Asia and America),

as reported in a new study carried out by Brandeis University researchers and published in

American Journal of Tropical Medicine and Hygiene, is roughly $2.1 billion each year. Brazil

alone spends 1.2 billion US $ each year in vector control. This has been found to be more

than the loss incurred from other viral diseases such as HPV(most widespread STD) and

Rotavirus (major cause of fatal diarrhea in children throughout the world)

The indirect impact of dengue , According to the estimates of the Brandeis University’s

study group, 60% of the economic damage due to dengue is the result of productivity losses

that affect households, employers and government and loss in output in industrial and service

sectors due to affected employees inability to attend work. Also, fear inducted by mass media

which keeps tourists away from dengue affected zones. This results in a loss in the tourism

and other departments. These are the indirect costs. Direct costs are the usual medical care

cost. In countries like India and Africa, conducting studies to evaluate effect of dengue on

economy is difficult due to lack of government initiatives in carrying helpful documentation.

Recently the number of reported cases has continued to increase and explosive outbreaks are

occurring. The threat of a possible outbreak of dengue fever now exists in Europe and local

transmission of dengue was reported for the first time in France and Croatia in 2010 and

imported cases were detected in 3 other European countries. In 2012, an outbreak of dengue

on the Madeira islands of Portugal resulted in over 2000 cases and imported cases were

detected in mainland Portugal and 10 other countries in Europe.

In 2014, trends indicate increases in the number of cases in the People's Republic of

China, the Cook Islands, Fiji, Malaysia and Vanuatu, with Dengue Type 3 (DEN 3) affecting

the Pacific Island countries after a lapse of over 10 years. Dengue was also reported in Japan

after a lapse of over 70 years. In 2015 an increase in the number of cases was reported in

Brazil and several neighbouring countries.

Risk Factor of Dengue Fever Globally

- Urbanization in tropical countries that leads to increase in number of construction site

to accommodate the growth.

- Rapid population growth and rural-urban migration.

- Inadequate basic urban infrastructure (eg. unreliable water supply leading

householders to store water in containers close to homes) and increase in volume of

solid waste, such as discarded plastic containers and other abandoned items which

provide larval habitats in urban areas.

- Improper disposal of tyres which easily accumulate rainwater and act as a breeding

site for mosquitoes

- Increased air travel and breakdown of vector control measures have also contributed

greatly to the global burden of dengue and DHF

Risk Factor of Dengue Fever Related To The Patient

- Patient lives in a suburban area that were known to be a Dengue- prone area with

multiple cases of Dengue Fever reported among her neighbours.

- Patient and her siblings frequently plays outside the house duringAedes mosquitoes

active period.

- Patient’s house is situated nearby to a construction site that is prone to act as a

mosquito breeding site.

- The general cleanliness of the neighbourhood was subpar with presence of multiple

scattered water storage containers, improper placement and closure of bins and plant

pots that contain stagnant water. These, too, can act as mosquitoes breeding sites.

According to the mother, whenever fogging was done to terminate mosquitoes, it was

done only at the perimeter of the house and neighbourhood but not inside the house.

ACKNOWLEDGEMENT

In completing our clinicosocial case study, it is made possible through the help and support

form our beloved and respected people, in which we always look up to in our lives. In this

very special occasion, we would like to express our deepest gratitude and appreciation to Dr.

Maher, Head of Community Medicine unit, International Medical School, Management and

Science University, for giving us a guideline for our case throughout numerous consultation

and to Dr. Jasmeet Singh, Director of Hospital Kuala KubuBaru and his staffs for allowing us

to approach patients in the ward. Thank you to both doctors for giving us this golden

opportunity to learn more about public health sector in Malaysia.We would like to expand

our gratitude to our patient Alya and her family to give us good cooperation during clerking,

with warmest welcome for us to visit their house. Therefore, helping us in completing our

task successfully. We also would like to thank our hardworking team members and previous

group members that lend a helping hand to make comment suggestions which gave us

inspiration to improve our case write up and not to forget to all those who have directly and

indirectly guided us in writing this clinicosocial case study.

CONCLUSION

In a nutshell, we can conclude that Alya’s medical condition is due to the environmental

factors which is lack of awareness and negligence attitude in the community towards

cleanliness that encourage development of breeding sites and spreading of disease affecting

members of the family and community. Thus, proper preventive measures done at various

levels from family up to national level should be implemented in order to eradicate dengue

disease by breaking the chain of breeding cycle.

ABSTRACT

The clinico-social case study was done to learn the people living of people correlation with

health issues. This particular case was taken from a district Hospital which is Hospital Kuala

KubuBahru and the case was further investigated in patient’s house which was located in

PuncakAlam, Selangor. Alya is a 7 years old female girl has been diagnosed with dengue

fever for 5 days, lost of appetite, and loose stool with warning signs (persistent vomiting,

arthralgia and myalgia and epigastric pain) and developed rash on the fifth days upon

admisssion. On investigation, her platelet was decreased to 140 from the normal range. Her

physical examination was done with pulse rate and respiratory rate rise up to 158 beat per

minute and 36 breaths per minute. She lives in dengue endemic area with no history of

travelling. Dengue fever can be prevented by 3 stages which are primary, secondary and

tertiary levels that can be done at various level from patient to globally.

RECOMMENDATIONS

There are few recommendation suggested to improvise medical condition of Alya. It includes

the three stages of prevention that are primary, secondary and tertiary. Primary prevention

starts with eliminating the breeding sources and control of infectant mosquitoes. The child

should be taught to wear long pants, long sleeves to prevent mosquito bites and limiting

exposures by staying indoors for two hours after sunrise and before sunset. By using repellent

spray that contain DEET (N,N-diethyl-3-methylbenzamide), applyliquids, creams, lotions or

sticks to exposed skin, and netting can also help prevent mosquito bites. The community

should play their role by checking and removing stagnant water in the pots, containers, pails

and cans outdoor. They also should check the flow of water drainage, change water in flower

vases, wash root of flowers, clear fallen leaves, plastic, polystyreneeveryday. Clean and scrub

the inner sides of the vases thoroughly to remove the mosquito eggs and add granular

insecticide into vases regularly. The community should do their part by taking part in

"Gotong-Royong" to keep their neighbourhood clean by eliminating the breeding source so

that their neighbourhood free from dengue. The fogging part and house inspection should be

undertaken by the local authorities. Besides that, the government should enact the laws

concerning to the punishment regulations and to check performance of each country.

Campaign, health education, role of mass media are vital in creating awareness about the

disease.

Next is by implementing the secondary prevention. It is mainly to construct monitoring

number of cases of the disease and to stop the local dengue fever. The doctors and the related

personnel who discover suspected cases, should report within 24 hours.After receiving report

of the cases of disease, the authority shall investigate the nearby area of the household and

possible epidemic area to proceed to investigation of density of the larva and grown

mosquitoes. It is also important in upgrading the effectiveness of lab diagnosis and to

upgrade the ability in inspection of dengue hemorrhagic as the proper measure to guard

against the epidemic.

The target of tertiary prevention is to reduce the death rate of dengue hemorrhagic fever. This

can be done by carry out compulsory education on dengue hemorrhagic fever for medical

personnel on a continuous basis and improve main hospitals in treating fatal dengue

hemorrhagic fever in any emergency cases.

Globally, there should be continuous international cooperation and medical conference done

in order to exchange dengue fever prevention experiences, share information together, to

promote prevention/medical treatment more internationally and to promote knowledges of

the specialists. Integrated surveillance, outbreak preparation and future vaccine

implementation can help to reduce burden of dengue.

As we all know, prevention is better than cure. Therefore, everyone must play their part

indeed to prevent dengue from spreading and killing innocent people.

DISCUSSION

AlyaMaisarah is a 7 years old female girl has been diagnosed with dengue fever for 5 days,

lost of appetite, and loose stool with warning signs (persistent vomiting, arthralgia and

myalgia and epigastric pain) and developed rash on the fifth days upon admission. On

investigation, her platelet was decreased to 140 from the normal range. Her physical

examination was done with pulse rate and respiratory rate rise up to 158 beat per minute and

36 breaths per minute. She lives in dengue endemic area with no history of travelling.

Dengue fever is a vector-borne disease caused by infection by dengue virus transmitted by

female mosquito mainly of species Aedesaegypti and Aedesalbopictus. Dengue virus has

different serotypes there are DEN-1, DEN-2, DEN-3, and DEN-4. Recovery from infection

by one provides lifelong immunity against that particular serotype. Infected humans are the

main carriers and multipliers of the virus, serving as a source of the virus for uninfected

mosquitoes. It can be classified by dengue (with warning sign and no warning sign) and

severe dengue (severe shock +/-: respiratory distress, severe hemorrhage and organ failure)

The incubation period is 4-10 days. Dengue has three phases that are febril phase, critical

phase and recovery phase. The Aedesaegypti mosquito lives in urban habitats and breeds

mostly in man-made containers. Unlike other mosquitoes Ae.aegypti is a day-time feeder; its

peak biting periods are early in the morning and in the evening before dusk. Female

Aedesaegyptibites multiple people during each feeding period. Aedesalbopictus, a secondary

dengue vector in Asia,largely due to the international trade in used tyres (a breeding habitat)

and other goods. Aedesalbopictus is highly adaptive and, therefore, can survive in cooler

temperate regions of Europe. Its spread is due to its tolerance to temperatures below freezing,

hibernation, and ability to shelter in microhabitats. Aedesmosquito act as the vector, human

as a host, dengue virus as the agent and the temperature/ tropical country as the environment

factor.

Dengue should be suspected when a sudden and continuous high fever (40°C) is

accompanied by 2 of the following symptoms: severe headache, pain behind the eyes, muscle

and joint pains, nausea, vomiting, swollen glands or rash. Symptoms usually last for 2–7

days, after an incubation period of 4–10 days after the bite from an infected mosquito.Severe

dengue is a potentially deadly complication due to plasma leaking, fluid accumulation,

respiratory distress, severe bleeding, or organ impairment. After 3–7 days warning sign will

occur, the first symptoms in conjunction with a decrease in temperature (below 38°C) and

include: severe abdominal pain, persistent vomiting, rapid breathing, bleeding gums, fatigue,

restlessness and blood in vomit. The next 24–48 hours of the critical stage can be lethal;

proper medical care is needed to avoid complications and risk of death.

One recent estimate indicates 390 million dengue infections per year (95% credible interval

284–528 million), of which 96 million (67–136 million) manifest clinically (with any severity

of disease).(WHO, 2013). Another study, of the prevalence of dengue, estimates that 2.5

billion people, in 100 countries, are at risk of infection with dengue viruses.(WHO, 2012).

A total of 108,698 dengue cases in Malaysia were reported which is equivalent to IR of 361.1

cases in 100,000 populations in that year.

Patient living in the endemic area which prone to get the disease. During the visit, we have

noticed that there was lack of awareness and negligence attitude among society. Her elder

sister and her friends at school having this disease at the same time due to communicable

disease. Patient’s neighbours does not practice proper hygiene where there are abandon pots

and water containers. There is one death case 200 meter radius from patient’s house. Lack of

awareness is also one of the main reason the patient get infected because the parents let their

child play outside during aedes active period.However, the patient’s house is maintained

clean because she practice proper preventive measure where she use biological control

(guppy fish) in the aquarium and change the water every week in the aquarium. There are

also no abandon water containers and pots indoor and outdoor. They also use mosquito

repellent sprays. Residence association has conducted ‘gotong-royong’ during this outbreak

in the area. Law reinforcement in the area where fine is charged and fogging was done soon

after Alya discharged from the hospital.

She was admitted for 3 days and was treated with fluids, paracetamol and bed rest and she

was advised to drink a lot of water and fruits upon discharged.

The global incidence of dengue has grown dramatically in recent decades and about half of

the world's population is now at risk. So, in order to prevent this disease to keep on rising in

the future, a few preventive measure must be taken at various level. Family and society

should cultivate awareness and daily habit about cleanliness of the neighbourhood thus

prevent infection. While local authority should educate the society about dengue by doing

campaigns and through mass media. Vector control and law reinforcement should be

implemented continuously. Cases must be notified within 24 hours.Globally, there should be

continuous international cooperation and medical conference done in order to exchange

dengue fever prevention experiences, share information together, to promote

prevention/medical treatment more internationally and to promote knowledges of the

specialists.

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INTERNATIONAL MEDICAL SCHOOL

MBBS YEAR 4

COMMUNITY MEDICINE

CLINICOSOCIAL CASE REPORT

STUDENT’S NAMES:

1. ANITA NUR SUHAILA BINTI AZLAN 0120120505622. MUHAMMAD KHAIRI BIN TAJUL ANNWAR 0120120502283. PAVITHAR KAUR A/P PARABVIR SINGH 0120120502324. POOJA A/P SURESH 0120120505665. SHEREENA NAZLISA BINTI MOHAMMAD NAZLY 0120121001446. SITI NADHIRAH BINTI SALLEH 0120121000277. SITI NORSALWA BINTI AZMI 0120121000378. SITI SARAH BINTI MD ZAHID 012012100176

HEAD OF DEPARTMENT: DR MAHER D. FUAD FUAD

Documents

Clinicosocial Case Dengue