a case of n.e. 16 y.o male cc: fever x 3 days. history of present illness 3 days ptc: (+) fever...
TRANSCRIPT
![Page 1: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/1.jpg)
A Case of N.E.16 y.o Male
cc: fever x 3 days
![Page 2: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/2.jpg)
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
(-) epistaxis(-) gum & aural bleeding(-) hematemesis(-) hematuria(-) hematochezia(-) melena(-) petechiae/ ecchymoses/ rash
Px has a neighbor diagnosed with Dengue
![Page 3: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/3.jpg)
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
• (-) calf pain• (-) abdominal pains• (-) jaundice• (+) good urine output• (-) hx of wading through
the floodwaters
![Page 4: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/4.jpg)
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
Medications taken:
Paracetamol 500mg/tab every 4 hours for fever with minimal relief
![Page 5: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/5.jpg)
Review of Systems
(-) dizziness(-) difficulty of breathing(-) chest pains(-) palpitations(-) weight loss >20%(-) decrease in appetite
![Page 6: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/6.jpg)
Past Medical History
(-) hypertension, diabetes, liver, lung and kidney disease
(-) asthma, allergies to food and drugs (-) previous hospitalizations and surgeries
![Page 7: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/7.jpg)
Birth and Maternal History
Pt was born FT at Fabella hospital by an OB-Gyne via SVD to a then G1P0 mother.
(-) maternal illness, exposure to chemicals, radiation
(-) exposure to measles and varicella infection
![Page 8: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/8.jpg)
Immunization History
completed the EPI c/o LHC(+) MMR c/o private pediatrician
![Page 9: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/9.jpg)
Nutritional History
Px was fed with both breastmilk and formula since birth.
The patient’s current diet consists of rice, meat, fish, poultry, with minimal fruits and vegetables
![Page 10: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/10.jpg)
Personal and Social History
H - good rel’p with parents & siblingsE - 2nd year HS, satisfactory performance, (-)
failing gradesA - basketball, computer gamesD - no use of illicit drugsS - has groups of friends in school and
neighborhoodS - not sexually activeS - no suicidal thoughts
![Page 11: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/11.jpg)
Personal and Social History
Non-smoker, occasional alcoholic beverage intake
Px lives with his mother and 2 other siblings at home in Pasay City
Mother is the breadwinner of the family and works in a factory
Px’s family gets monthly stipend from relatives who work abroad
![Page 12: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/12.jpg)
GenogramHPNAsthma
CVDPTB
32 30 27 24 16
7 9
![Page 13: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/13.jpg)
Physical ExaminationBP 90/60 HR 120s RR 20 T 38.6Px is awake, coherent, oriented, weak-lookingPinkish conjunctivae, anicteric sclerae, (+) pharyngeal
injection, (-) cervical lymphadenopathies, (-) anterior neck masses, (-) nasoaural bleeding, (-) gum bleeidng
Equal chest expansion, clear breath sounds, (-) wheezes, (-) crackles, (-) retractions
Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs
Soft and flat abdomen, normoactive bowel sounds, (-) masses/ tenderness, liver and spleen nonpalpable
Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-) clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses, (-) calf tenderness, (+) flushed skin
![Page 14: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/14.jpg)
Tourniquet Test
negative (<20 spots in 1 square inch)
![Page 15: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/15.jpg)
Assessment
R/O Dengue Fever/ Dengue Hemorrhagic Fever
![Page 16: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/16.jpg)
Plan
For CBC with platelet countParacetamol 500mg/tab 1 tab every 4
hours for feverTepid sponge bathSupportive therapy
Increase oral fluid intakeAvoid dark colored foodsWOF bleeding episodes
![Page 17: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/17.jpg)
Questions Questions…..
What if the CBC was normal? It has only been a 3 day Hx of fever..
A negative tourniquet test doesn’t necessarily r/o DF/DHF.. What now?
Its too early to say.. What can we do at this point? Is watchful waiting enough to prevent the complications of DF/DHF?
Recent dengue cases are noted to be more virulent than the past (cross-immunities etc)
![Page 18: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/18.jpg)
DF/DHF Epidemiology
10,383 cases of DF/DHF noted by Nat’l Epidemiological Center of DOH (Jan-June 20)
104 deaths (case fatality of 1%)Most cases were at NCR, Region 4A, 5,6Most deaths are caused by complications
secondary to DHF and DSSMost are diagnosed LATE
![Page 19: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/19.jpg)
Bio-Rad Dengue NS1 Antigen Test
New offer at PGH Central Lab!!Used in private hospitals since 2007 serum available in minutesMay detect 4 dengue serotypes in the
first 5 days of viremia (febrile phase)
![Page 20: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/20.jpg)
Diagnostic Dilemma
P - pediatric patients with clinical signs of Dengue Fever, in the first 3 days of fever
I - Dengue NS1Antigen testC - virus isolation testO - sensitivity and specificity in diagnosis
of Dengue FeverM - cross sectional study
![Page 21: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/21.jpg)
Clinical Question (Diagnostics)
What is the sensitivity and specificity of Dengue NS1Antigen test versus a viral isolation test in the diagnosis of DF/DHF in pediatric patients with clinical signs of DF in the first 3 days of viremia in a cross sectional study?
![Page 22: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/22.jpg)
Therapeutic Dilemma
P - Pediatric patients with clinical signs of systemic viral infection (SVI)
I - ImmunologicalsC - placeboO - shortening the course of the diseaseM - RCTs
![Page 23: A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized](https://reader035.vdocument.in/reader035/viewer/2022062409/5697bfc11a28abf838ca4126/html5/thumbnails/23.jpg)
Clinical Question (Therapeutics)
In pediatric patients with clinical signs of systemic viral infection, is there a significant difference in giving immunologicals versus placebo in shortening the course of fever seen in randomized controlled trials?