Dengue case pres

General Objective To present a case of a patient presenting

with Fever

Specific Objective To discuss the history and physical

examination findings relevant to the case

To be able to formulate a clinical impression based from the history and PE

To identify possible differential diagnoses according to the given case

To be able to correlate case discussion with the condition of patient

History of Present IllnessTime Frame Pertinent (+) Pertinent (-) Remarks

3 days PTA • Sudden onset of documented fever (39.3’C)

• Vomiting of 2-3 episodes of previously ingested food

• No Cough• No LBM• No Dysphagia• No Dysuria

• No consult • Paracatemol

1tbsp 3x a day

7 hours PTS • Sudden onset of abdominal pain

(epigastric area, non-radiating)• Still with

vomiting• No fever

• No epistaxic• No melena• No LBM

• No meds taken• Sought consult

at private MD and was advised admission

PAST MEDICAL HISTORY No previous hospitalization No surgical history No known allergies to food or

medicationsFAMILY HISTORY

• Denies Herido-Familial Disease

PERSONAL and SOCIALHISTORY

Mother – 25 y.o. G3P3 – PNCU Father – 36 y.o. – MV Delivered via CS at this institution 2nd among the 3 siblings He lives with his parents and 2 siblings.

Immunization Status Patient is completely immunized single dose BCG 3 doses of DPT, OPV and Hepa-B vaccines single dose of measles vaccine

Feeding History

Review of System

General: (-) weight loss, (-) lethargy, (-) easy fatigability Skin: (-) itching HEENT: (-) epistaxis, (-) dizziness Cardiovascular: (-) palpitations, (-) orthopnea,(-)chest pain Gastrointestinal: (-) constipation, (-) diarrhea, (-) blood in

the stool Genito-urinary: (-) frequency, (-) dysuria, (-) hematuria,

Endocrine: (-) excessive sweating, (-) heat/cold intolerance Musculoskeletal: (-) joint pain, (-) stiffness Extremities:(-) paresthesia, (-) numbness Neurologic: (-) seizure, (-) loss of consciousness

Physical Examination General: awake, weak-looking, cold and clammy

VITAL SIGNS: T: 36.3 C Pulse Rate: 123 bpm Respiratory Rate: 29 cycles per minute BP: Palpatory 70

Weight: 20.5 kgs Height: 116cm

Stunting: Wasting (+) Tourniquest test

Physical Examination SKIN: (+) petechiae, ecchymoses, no wounds HEENT:

Head: Normocephalic; Hair is black, has equal distribution and average texture; No lumps; No tenderness

Eyes: pink palpebral conjunctiva; Anicteric sclera; pupils equally reactive to light 2-3mm

Ears: No discharges; Acuity is good to speaking voice Nose: Pink Nasal Mucosa, No discharges, No

tenderness Mouth and throat: (-) gum swelling or bleeding, (-)

tonsillar enlargement, pink buccal mucosa NECK: No visible neck mass; No thyroid enlargement,

No cervical lymphadenopathies

Physical Examination CHEST & LUNGS

Equal chest expansion, No retractions; No lesions, No tenderness; No mass; Clear breath sounds

CARDIOVASCULARAdynamic precordium; apical beat at the 5th left I

ntercostal space, MCL; RRR; No murmurs

ABDOMENFlat; Normoactive bowel sounds; Tympanitic; No

hepatosplenomegaly; Soft; Tenderness on Right Upper Quadrnt

EXTREMITIESCold and clammy, No edema, No varicosities, poor

and thready brachial and radial pulses; CRT ˂ 2sec.

Clinical Impression

Dengue Shock Syndrome

Basis History

Sudden onset of high grade fever Vomiting Abdominal pain 3rd day : Afebrile

PE Bp: palpatory 70 PR: 123 T: 36.3 ‘C Cold and clammy skin (+) tenderness RUQ (+) poor and thready pulses (+) tourniquet test

Differential Diagnoses

Ruled- In Ruled- Out

1. Acute TonsilloPharyngitis

(+) Fever (-) Dysphagia(-) swollen tonsils

2. Urinary Tract Infection

(+) Fever(+) vomiting(+) abdominal pain

(-) dysuria

3. Typhoid fever (+) Fever

4. Malaria (+) Fever

Course in the wardMarch 25, 2015 (On admission) 4:40PM

S O A P3rd Day of Illness1st Day Afebrile (+) Abdominal pain(+) vomitingAfebril: 36.3

VS:

Bp: Palpatory 70T: 36.3’CP: 123 bpmR: 29cpmO2sat: 96%

Awake, weak-looking, cold and clammy skinAS, PPC, (+) sunken eyeballsECE, CBSAP. Tachycardic, (-) murmurFlat, NABS, (+) tenderness RUQPoor and thready pulses

(+) Tourniquet test


• Admit to W8-ICU• DAT except dark

colored food• IVF: PLR1L to run @

36gtts/min x 2hrs then refer for RA

• Start another line with PNSS 1L to run @ 400cc FDx 2 then refer for RA

• Labs: -CXR APL - Cbc, plt, BT -serial hct/plt q6 -dengue NS1Meds:• Paracetamol 200mg

IVT PRN q 4 for T>38

• Ranitidine 14mg IVT now then q8

• Monitor VS and BP q1

• Monitor I and O q shift

• Refer for bleeding, hypotension, narrow pulse pressure

Course in the wardMarch 25, 2015 (On admission) 6:40PM

S O A P

(+) Abdominal painAfebril: 36.5’C

VS:

Bp: 110/80T: 36.5’CP: 120 bpmR: 25cpmO2sat: 96%

Awake, weak-looking, AS, PPC, (+) sunken eyeballsECE, CBSAP. Tachycardic, (-) murmurFlat, NABS, (+) tenderness RUQGood pulses

TFI: 5cc/kg


• Hold IVF PNSS, then PLR 1L to run @ 26 gts/min in 4 hours then refer for RA

Course in the wardMarch 25, 2015. 10PM

S O A P

(+) Abdominal painAfebril: 36.5’C

VS:


Awake, NIRDAS, PPC, (-) sunken eyeballsECE, CBSAP. Tachycardic, (-) murmurFlat, NABS, (+) tenderness RUQGood pulses

Hct: 0.50 Plt: 20BT: B +TFI: 5cc/kg


• Cont IVF with PLR 1L to run @ 25gtts/min in 4 hours then refer fro RA

• Cont meds• Ff up labs• Refer accordingly

Course in the wardMarch 26, 2015 @ 4AM

S O A P

4th Day of Illness2nd day Afebrile(+) Abdominal pain(-)bleeding episodes(-)DOBAfebril: 36.5

VS:


TFI: 5cc/kg

Awake NIRDAS PPCECE, CBSAP, tachycardicGlobular, NABS, (+) RUQ tendrnessGood pulses


• Cont IVF with PLR 1L to run @ 25gtts/min in 4 hours then refer fro RA

• Cont serial hct/plt q^

• Refer accordingly

Course in the wardMarch 26, 2015 @ 6AM

S O A P

(+) Abdominal pain(-)bleeding episodes(-)DOBAfebril: 36.5

VS:

Bp: 90/60T: 37’CP: 100 bpmR: 28cpmO2sat: 99%

TFI: 5cc/kg

Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses

UO: 100mlHct: 0.50Plt: 18


• IVF PLR 1L to run @ 36gtts/min in 2 hours then refer for RA

• Cont meds• Cont VS and BP q 1• Cont serial hct/ plt

q6• Cont I and O q shift• Refer for bleeding,

narrow pulse pressure and hypotension

Course in the wardMarch 26, 2015 @ 9:15 AM

S O A P

(+) Abdominal pain(+) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.5

VS:


TFI: 7cc/kg


UO: Hct: 0.52Plt: 20






Course in the wardMarch 26, 2015 (2:10PM)

S O A P


VS:

Bp: 110/80T: 36.5’CP: 100 bpmR: 27 cpmO2sat: 99%

TFI: 7cc/kg








Course in the wardMarch 26, 2015 (6 PM)

S O A P


VS:


TFI: 7cc/kg


UO: Hct: 0. 55Plt: 20


• IVF PLR 1L to run @ 205 cc in 1 hour den regulate to 36gtts/min in 2 hours then refer for RA

• Start omeprazole 10mg IVTT now the q12

• Cont VS and BP q 1• Cont serial hct/ plt

q6• Refer for bleeding,


Course in the wardMarch 26, 2015 (9 PM)

S O A P

(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.5

VS:


TFI: 7cc/kg


UO: Hct: Plt:



• Refer for bleeding, narrow pulse pressure and hypotension

Course in the wardMarch 27, 2015 (12:30 AM)

S O A P

5th day of Illness3rd day Afebrile(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.3

VS:


TFI: 5cc/kg






Course in the wardMarch 27, 2015 (6 AM)

S O A P


VS:


TFI: 3cc/kg


UO: Hct: Plt:




q6• Refer for bleeding,


Course in the wardMarch 27, 2015 (11:20 AM)

S O A P


VS:


TFI: 3cc/kg


UO: Hct: Plt:




Course in the wardMarch 27, 2015 (11:20 PM)

S O A P


VS:


TFI: 2cc/kg

Awake NIRDAS PPCECE, dec breath sounds BibasalAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses

UO: Hct: Plt:

Dengue Shock Syndrome T/C pleural effusion

• Terminate PNSS line and place to heplock


• CXR PAL• Hook o 02 at 3LPM• Refer for bleeding,


Course in the wardMarch 27, 2015 (511:50PM)

S O A P


VS:


TFI: 2cc/kg


UO: Hct: Plt:

Dengue Shock Syndrome; pleural effusion

• Monitor prsent IVF to run @ 10gtts/min in 4 hours then refer for RA


Course in the wardMarch 28, 2015 (6:15AM)

S O A P


VS:


TFI: 2cc/kg


UO: Hct: Plt:

Dengue Shock Syndrome; pleural effusion

• Monitor prsent IVF to run @ 10gtts/min in 4 hours then refer for RA


CASE DISCUSSIONDengue is the most rapidly spreading mosquito-borne viral disease in the world

Dengue virus (DEN) is a small single-stranded RNA virus comprising four distinct serotypes(DEN-1 to -4).

Belongs to Flaviviridae family

CASE DISCUSSIONTransmission of Dengue virus is primarily transmitted by Aedes mosquitoes, particularly Aedes Aegypti. Other Aedes species that transmit the disease include:

1. Aedes Albopictus,2. Aedes Polynesiensis 3. Aedes Scutellaris.

Mosquito Life cycle

The Host Humans are the primary host of the

virus Incubation period: 4-10 days

Case Classification and level of severity1. Dengue without warning signs

Probable dengueLive in/travel to dengue endemic area. Fever and 2 of the following criteria:• Nausea, vomiting• Rash• Aches and pains• Tourniquet test positive• Leucopenia• Any warning sign

Laboratory confirmed dengue (important when no sign of plasma leakage)

The course of dengue illness

Febrile Phase The acute febrile phase usually lasts 2-7 days Mild hemorrhagic manifestations like petechiae

andmucosal membrane bleeding (e.g., nose and gums) The earliest abnormality in the full blood

count is a progressive decrease in total white cell count

CLINICAL SIGNS AND SYMPTOMS

• Fever, Headache, Body malaise, Myalgia, Arthralgia, Retro-orbital pain, Anorexia, Nausea, Vomiting, Diarrhea, Flushed skin,

Rash (petechial, Hermann’s sign)AND

• Laboratory test, at least CBC (leucopenia withor without thrombocytopenia) and/or dengueNS1 antigen test or dengue IgM antibody test

(optional)

Critical Phase

Defervescence occurs on day 3-7 of illness Around the time of defervescence, patients can

either improve or deteriorate. Warning signs are the result of a significant

increase in capillary fragility. This marks the beginning of the critical phase.

The period of clinically significant plasma leakage usually lasts 24 to 48 hours.

Recovery Phase

A gradual re-absorption of extravasated fluid from the intravascular to the extravascular space (e.g., pleural effusion, ascites) by way of the lymphatics will take place in the next 48-72 hours.

Case Classification and Levels of Severity

Dengue without Warning SignsProbable dengue: Lives in or travels to dengue-endemic area, with fever, plus any two of the

following:• Headache• Body malaise• Myalgia• Arthralgia• Retro-orbital pain• Anorexia• Nausea• Vomiting• Diarrhea• Flushed skin• Rash (petechial, Hermann’s sign)

AND• Laboratory test, at least CBC (leucopenia with orwithout thrombocytopenia) and/or dengue NS1 antigentest or dengue IgM antibody test (optional)

Confirmed dengue:• Viral culture isolation PCR


Dengue with Warning SignsProbable dengue:Lives in or travels to dengue-endemic area, with feverlasting for 2-7 days, plus any of the following:

• Abdominal pain or tenderness• Persistent vomiting• Clinical signs of fluid accumulation• Mucosal bleeding• Lethargy, restlessness• Liver enlargement• Laboratory: increase in Hct and/or decreasing plateletcount

Confirmed dengue:• Viral culture isolation• PCR


Severe DengueLives in or travels to a dengue-endemic area with feverof 2-7 days and any of the above clinical manifestationsfor dengue with or without warning signs, plus any ofthe following:• Severe plasma leakage, leading to:- Shock- Fluid accumulation with respiratory distressSevere bleeding• Severe organ impairment- Liver: AST or ALT >1000- CNS: e.g., seizures, impaired consciousness- Heart: e.g., myocarditis- Kidneys e.g., renal failure

PARACLINICALS

CBC, platelet, blood typing Serial hematocrit and platelet ALT, AST Dengue NS1 (1st-5th day of Illness) Dengue duo (5th day to 6 months of

illness)

Management GROUP A – Patients who may be sent home

Action Plan Oral rehydration solution (ORS) should be given based on

weight, using currently recommended ORS: Reduce osmolarity of ORS containing sodium 45 to 60 mmol/liter Sports drinks should NOT be given due to its high osmolarity

which may cause more danger to the patient.

Calculation of Oral Rehydration Fluids Using Weight (Ludan Method)Body weight (kg) ORS to be given

>3-10 100 mL/kg/day>10-20 75 mL/kg/day>20-30 50-60 mL/kg/day>30-60 40-50 mL/kg/day

Management GROUP B – Patients who should be referred for

inhospital management

a. Dengue without Warning Signs

Encourage oral fluids. If not tolerated, start intravenous fluid therapy of 0.9% NaCl (saline) or Ringer’s Lactate with or without dextrose at maintenance rate

Management

Management f the patient shows signs of mild dehydration but

is NOT in shock, the volume needed for mild dehydration is added to the maintenance fluids to determine the total fluid requirement (TFR).

Periodic assessment is needed Clinical parameters should be monitored closely

and correlated with the hematocrit. The IVF rate may be decreased anytime as

necessary based on clinical assessment. If the patient shows signs of deterioration see

Management for Compensated or Hypotensive Shock, whichever is applicable.

Managementb. Dengue with Warning Signs

1. Obtain a reference hematocrit before fluid therapy2. Give only isotonic solutions such as 0.9% NaCl (saline), Ringer’s Lactate, Hartmann’s solution.

Start with 5-7 mL/kg/hour for 1-2 hours, then reduce to 3-5 mL/kg/hr for 2-4 hours, and then reduce to 2-3 mL/kg/hr or less according to clinical response

3. Reassess the clinical status and repeat the hematocrit4. If the hematocrit remains the same or rises only minimally, continue with the same rate (2-3 mL/kg/hr) foranother 2-4 hours.5. If there are worsening of vital signs and rapidly risinghematocrit, increase the rate to 5-10 mL/kg/hour for 1-2 hours

Managementb. Dengue with Warning Signs

6. Reassess the clinical status, repeat hematocrit and review fluid infusion rates accordingly7. Give the minimum intravenous fluid volume required to maintain good perfusion and urine output of about 0.5 mL/kg/hr. Intravenous fluids are usually needed for only 24 to 48 hours.8. Reduce intravenous fluids gradually when the rateof plasma leakage decreases towards the end of thecritical phase. This is indicated by:

• Urine output and/or oral fluid intake is/are adequate,or• Hematocrit decreases below the baseline value ina stable patient

Documents

Dengue case pres