dengue case pres
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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
Dengue Shock Syndrome
• 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
Dengue Shock Syndrome
• 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:
Bp: 100/70T: 36.5’CP: 111 bpmR: 25cpmO2sat: 96%
Awake, NIRDAS, PPC, (-) sunken eyeballsECE, CBSAP. Tachycardic, (-) murmurFlat, NABS, (+) tenderness RUQGood pulses
Hct: 0.50 Plt: 20BT: B +TFI: 5cc/kg
Dengue Shock Syndrome
• 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:
Bp: 90/60T: 36.5’CP: 11 bpmR: 22cpmO2sat: 96%
TFI: 5cc/kg
Awake NIRDAS PPCECE, CBSAP, tachycardicGlobular, NABS, (+) RUQ tendrnessGood pulses
Dengue Shock Syndrome
• 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
Dengue Shock Syndrome
• 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:
Bp: 90/60T: 36.9’CP: 115 bpmR: 23cpmO2sat: 99%
TFI: 7cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: 0.52Plt: 20
Dengue Shock Syndrome
• 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 (2:10PM)
S O A P
(+) Abdominal pain(+) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.5
VS:
Bp: 110/80T: 36.5’CP: 100 bpmR: 27 cpmO2sat: 99%
TFI: 7cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: 0.55Plt: 20
Dengue Shock Syndrome
• 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 (6 PM)
S O A P
(+) Abdominal pain(+) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.5
VS:
Bp: 190/60T: 36.5’CP: 106 bpmR: 24 cpmO2sat: 99%
TFI: 7cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: 0. 55Plt: 20
Dengue Shock Syndrome
• 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,
narrow pulse pressure and hypotension
Course in the wardMarch 26, 2015 (9 PM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.5
VS:
Bp: 90/60T: 36.5’CP: 100 bpmR: 25 cpmO2sat: 99%
TFI: 7cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: Plt:
Dengue Shock Syndrome
• IVF PLR 1L to run @ 36gtts/min in 2 hours then refer for RA
• 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:
Bp: 100/60T: 36.3’CP: 100 bpmR: 25 cpmO2sat: 99%
TFI: 5cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: 0.41Plt: 13
Dengue Shock Syndrome
• IVF PLR 1L to run @ 26gtts/min in 6 hours then refer for RA
• Refer for bleeding, narrow pulse pressure and hypotension
Course in the wardMarch 27, 2015 (6 AM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.3
VS:
Bp: 90/60T: 36.3’CP: 100 bpmR: 25 cpmO2sat: 99%
TFI: 3cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: Plt:
Dengue Shock Syndrome
• IVF PLR 1L to run @ 16gtts/min in 4 hours then refer for RA
• Cont meds• Cont VS and BP q 1• Cont serial hct/ plt
q6• Refer for bleeding,
narrow pulse pressure and hypotension
Course in the wardMarch 27, 2015 (11:20 AM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.7
VS:
Bp: 100/70T: 36.3’CP: 105 bpmR: 23 cpmO2sat: 99%
TFI: 3cc/kg
Awake NIRDAS PPCECE, CBSAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: Plt:
Dengue Shock Syndrome
• IVF PLR 1L to run @ 16gtts/min in 4 hours then refer for RA
• Refer for bleeding, narrow pulse pressure and hypotension
Course in the wardMarch 27, 2015 (11:20 PM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.7
VS:
Bp: 100/70T: 36.3’CP: 110 bpmR: 47 cpmO2sat: 99%
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
• IVF PLR 1L to run @ 10gtts/min in 4 hours then refer for RA
• CXR PAL• Hook o 02 at 3LPM• Refer for bleeding,
narrow pulse pressure and hypotension
Course in the wardMarch 27, 2015 (511:50PM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.8
VS:
Bp: 100/70T: 36.8’CP: 70 bpmR: 28 cpmO2sat: 99%
TFI: 2cc/kg
Awake NIRDAS PPCECE, dec breath sounds BibasalAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: Plt:
Dengue Shock Syndrome; pleural effusion
• Monitor prsent IVF to run @ 10gtts/min in 4 hours then refer for RA
• Refer for bleeding, narrow pulse pressure and hypotension
Course in the wardMarch 28, 2015 (6:15AM)
S O A P
(+) Abdominal pain(-) headache(-) vomiting(-)bleeding episodes(-)DOBAfebril: 36.7
VS:
Bp: 100/70T: 36.8’CP: 102 bpmR: 26 cpmO2sat: 99%
TFI: 2cc/kg
Awake NIRDAS PPCECE, dec breath sounds BibasalAP, NRRR, (-) murmurGlobular, NABS, (+) RUQ tendernessGood pulses
UO: Hct: Plt:
Dengue Shock Syndrome; pleural effusion
• Monitor prsent IVF to run @ 10gtts/min in 4 hours then refer for RA
• Refer for bleeding, narrow pulse pressure and hypotension
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
Case Classification and Levels of Severity
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
Case Classification and Levels of Severity
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
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