BST PRESENTATION

Norman Nillson
 Patient’s Particular
Name Rahiman Abdul

Age 33 year-old

Gender Male

Occupation Security guard

Marital status Single

Religion Islam

Nationality Indonesian

Address Bukit Raja, Klang

Hospital/Ward/Bed HTAR/6F/27

DOA/DOC 6.11.2025 / 7.11.2025

Chief Complaint
High grade fever for 4 days associated with persistent
vomiting and skin rash
 History of Presenting Illness
Muhammad Rahman was well until 4 day before his admission where he developed Fever.

Fever - 4 Days
- Sudden onset
- Continuous
- Partially relieved by paracetamol 1g QID.
- The highest temperature recorded was 39.6 Degree.
- Associated with headache, retro orbital pain, myalgia & athralgia, loss of appetite and
fatigue.

Vomiting - 3 Days
- Persistent
- 5-6 Episodes, food content and fluid. Approximate volume 1-2 cup. No blood, no
billous.
- Associated with abdominal pain, epigastric region, dull with no radiation.
- No diarrhoea.
 History of Presenting Illness
Continue..

Skin Rash - 1 Days

- Generalised, started on the upper and lower limbs.
- Maculopapular rash
- Non itchy, no discharge, painless
- Otherwise, no gum bleeding, melena, hematemesis

There was no history of cough, dyspnea, chest pain, or altered sensorium. He denied
contact with sick persons, recent travel, or exposure to contaminated food or water.
 Systemic Review

System Relevant Symptoms

General / Weight loss, no confusion, drowsiness

Constitutional

Cardiovascular No palpitations, chest discomfort

Neurological No confusion, drowsiness

Genitourinary Oliguria, no dysuria, hematuria

 Other History

Past Medical & ● No known history of hypertension, diabetes mellitus, bronchial or

Surgical cardiac disease.
● No previous episode of dengue or other tropical illnesses.
● No prior surgeries or hospital admissions.

Drug & Allergy ● Took paracetamol 1 g every 6 hours for fever.

● Denies use of NSAIDs, aspirin, herbal remedies, or traditional
supplements.
● No known drug or food allergies.

Immunization ● No recent vaccinations or travel-related immunizations.

 Other History

Family ● Father: Alive, aged 68 years. He is a known case of Hypertension

for the past 15 years, on medication. No history of Ischemic
Heart Disease (IHD), Diabetes Mellitus, or malignancy.
● Mother: Alive, aged 65 years. She is a known case of Type 2
Diabetes Mellitus for 8 years, on medication. No history of
hypertension, asthma, malignancy, or genetic disorders.
● No history of premature cardiac death
● No positive family history of dengue infection, congenital
disease, or bronchial asthma.
● The patient has two siblings one elder sister (28 years old) and
one younger brother (21 years old).
● All siblings are alive and healthy.
 Other History

Social and ● Resides in a shared flat with two housemates.

Personal ● Good amenities.
● Frequent fogging in the housing area and there is active dengue
case
● Work as a security guard in a factory. Monthly income adequate.
● The patient is a current smoker, smoking approximately 20
cigarettes per day for the past 13 years. 13 pack years. No use
of vaping devices.
● No history of alcohol or recreational drug consumption.
● No history of multiple or unprotected sexual contacts.
 Physical Examination

General Appearance:
Ill-looking, febrile, lethargic but conscious
and oriented to time, place and person. Parameter Reading

He has IV cannula on his right dorsum of Temperature 38.8°C

hand.
Pulse 112 bpm, thready
Hydration Status:
Blood Pressure 95/70 mmHg
Mild dehydration, dry mucous
membranes, delayed skin turgor, cool Respiratory Rate 22 breaths/min
peripheries.
SpO₂ 98% (room air)
Anthropometry :
Weight - 78kg
Height - 166cm
BMI: 28.3 kg/m2
 Physical Examination
1. Skin and Mucosa

● Petechiae present over both upper and lower limbs.

● No ecchymosis or active bleeding.
● Capillary refill > 2 seconds.

2. Head, Eyes, Ears, Nose, Throat (HEENT)

● Conjunctival injection, no jaundice, no pallor.

● Oral mucosa moist, no gum bleeding, no central cyanosis
● No ear, nose discharge

3. Extremities

● Cold peripheries, prolonged capillary refill.

● No cyanosis or pedal edema.
 Physical Examination
Cardiovascular

Inspection ● No visible chest wall deformity or abnormal precordial

pulsation.
● No scars, dilated veins, or visible thrills.

Palpation ● Apex beat palpable at 5th intercostal space, midclavicular

line; not displaced.
● No parasternal heave.
● No palpable thrills.
● Peripheral pulses present but weak and thready. Capillary
refill time: >2 seconds.

Auscultation ● First and second heart sounds heard, regular rhythm.

● No murmur, rub, or gallop
 Physical Examination
Respiratory

Inspection Chest symmetrical with equal expansion bilaterally.

No use of accessory muscles of respiration.
No scars, deformities, or intercostal retraction noted.
Respiratory rate: 22 breaths/min.

Palpation Trachea central.

Chest expansion equal bilaterally.
Tactile vocal fremitus equal on both sides.

Percussion Percussion note resonant bilaterally.

No area of dullness detected.

Auscultation Vesicular breath sounds heard bilaterally.

No added sounds (no crepitations, rhonchi, or pleural rub).
 Physical Examination
Abdomen
Inspection Abdomen appears slightly distended.
No visible scars, striae, or dilated veins.
No visible pulsations or peristalsis.
Umbilicus centrally placed and inverted.

Palpation Abdomen soft, mildly tender over right hypochondriac region and
epigastrium.
No guarding or rebound tenderness.
Liver palpable 2 cm below right costal margin, smooth surface,
tender.
Spleen not palpable.
No palpable masses, kidney non ballotable

Percussion Liver span approximately 14 cm in midclavicular line..

No shifting dullness detected.

Auscultation Normal bowel sounds present.

 Diagnosis

Provisional Dengue fever with warning sign

Differential Leptospirosis
Typhoid fever
Malaria
Septic shock
Investigations
Investigations
 Management

● Admit to subacute bed, medical ward

● Hemodynamic monitoring
● Vital sign monitoring
● Strict input and output chart
● Hematocrit & Platelet every 6 hours
● Bed rest
● Paracetamol 1g QID, avoid NSAID
● Allow orally as tolerated
● 0.9 Normal saline, 800cc over 30 min stat, if not improve repeat bolus.
● If improve continue 0.9% Normal saline maintenance and taper down.
● Watchout for complications (Fluid overload, Pulmonary bleeding, severe/occult
bleeding)