AMARO. AMOLENDA. ANDAL. ANG. ANG

CASE CONFERENCE

General Data M.C. 14, Female April 29, 1996 Filipino Roman Catholic Sampaloc, Manila

Informant: Patient and Mother Reliability: Good

Chief Complaint Fever

History of Present Illness

Patient experienced fever graded > 40°C Paracetamol 500 mg/tab Q4 Ibuprofen 200 mg/capsule

Provided temporary relief. Bifrontal Headache

non-radiating, graded 3/10 (+) Non projectile vomiting of previously

ingested food (1 episode) (+) loss of appetite (-) Epistaxis, Abdominal Pain (-) Gum Bleeding, Dizziness (-) Cough, Colds, Dysuria, Diarrhea

4 DAYS PTC

History of Present Illness

Persistence of Fever Ibuprofen 200 mg

It provided temporary relief of symptoms.

(+) Loss of appetite (-) Epistaxis, Abdominal Pain,

Dizziness, Vomiting, Gum Bleeding (-) Cough, Colds, Dysuria,

Diarrhea

1 DAY PTC

History of Present Illness

Persistence of Fever Ibuprofen 200mg/capsule

Provided temporary relief of symptoms

(+) Myalgia, Loss of appetite (-) Epistaxis, Abdominal Pain (-) Dizziness, Gum Bleeding,

Vomiting (-) Cough, Colds, Dysuria,

Diarrhea

3 hoursPTC

Review of Systems General:, (-) weight loss/gain Skin: (-) rash, pigmentation Head: (-) visual difficulties, lacrimation,

aural discharge, nasal discharge Cardiovascular: (-) cyanosis, orthopnea Respiratory: see HPI Gastrointestinal: see HPI

Review of Systems Genitourinary: (-) oliguria, hematuria Endocrine: (-) heat/cold intolerance,

palpitations, polyuria, polydipsia, polyphagia

Nervous: (-) convulsions, tremors, sleep problems

Hematologic: (-) easy bruisability, bleeding manifestation

24 Hour Food Recall Bobby in table form po plus kCal and

RENI Ung kapanipaniwala… remember my

loss of appetite since 4 days PTC. Pero wag nmn sobrang baba kc baka sabihin dpt i-admit. TNX

Past Medical History Dysentery (2005)

Confined in Hospital ng Sampaloc

Menstrual History Menarche: 13 y/o Interval: Every 28-30 days Duration: 5-7 days Amount: 3 fully soaked napkins LMP: Aug 7-11, 2010 PMP: July 5-10, 2010

Immunizations Incomplete with unrecalled dates

BCG: 1 HepB: 3 DPT/OPV: 3 (without booster) Measles: 1 MMR: (unrecalled)

Family Profile (BOBBY AYUSIN MO PO ITO PLS.. TABLE FORM) Father

MC Age: 44 College Graduate Operator Healthy

Mother JC Age:44 College undergrad Housewife Healthy

Brother JC Age: 23 College undergraduate Healthy

Sister: JC Age: 21 College undergrad Housewife Healthy

Family History (+) HPN, Paternal relatives (+) Ovarian CA, maternal grandmother

Socioeconomic and Environmental Profile

Housing Condition: 2 storey house, made up of wood, well lit

and well ventilated. Patient consumed mineral water.Garbage is collected everyday and they practice segregation. They have 2 pet dogs and no factories nearby. The family’s average monthly income amounts to >P10, 000

Psychosocial History Home:

Lives with both parents, 2 siblings and her sister’s family. Has good relationship with other family members.

Education: Currently a 2nd year H.S. student at Ramon Magsaysay H.S. Good school performance, and gets along with teachers

and classmates. Eating:

Eats 3x a day + snacks Activities:

Part of Manila City Dance Scholars Listens to acoustic music, watches TV, and surfs the net.

Psychosocial History Drugs:

Denies illicit drug use Non smoker Non alcoholic beverage drinker

Suicide No suicidal ideation

Sexual No boyfriends Denies any sexual encounter

Safety Follows traffic rules and regulations

Physical Exam General Survey: Conscious, coherent, ill

looking, not in Cardiopulmonary distress, well nourished, and mildly dehydrated

Vital Signs- BP: 110/80, CR: 95, RR: 21, Temp: 36.5 °C

Ht: 155 cm (Z-score 0) Wt: 41.3 kg (Z- score ?) BMI: 17.2 (Z-score -1)

Physical Exam Skin: flushed skin with dry lips. Good skin

turgor, no active dermatoses, and (+) Tourniquet test

Eyes/Ears/Nose/Throat: Pink palpebral conjunctivae, anicteric sclerae, pupils 3-4 mm ERTL / No tragal tenderness, no ear discharge, (+) retained cerumen on both ears / non hyperemic PPA, moist buccal mucosa, no gum bleeding, no mouth sores, no palatal petechiae

Physical Exam Neck: Supple neck, no palpable cervical

lymph nodes Lungs/Chest: Symmetrical chest

expansion, no retractions or alar flaring, normal AP diameter, no cyanosis, no clubbing, tactile fremiti are equal on both lung fields, resonant on all lung fields. vocal fremiti are equal on both lung fields. clear breath sounds

Physical Exam Cardiovascular:Dynamic precordium, AB

at 5th LICS MCL, no heaves, lifts, and murmurs, S1>S2 at the apex, S2>S1 at the base

Abdomen: Flabby abdomen, normoactive bowel sounds, no masses, no direct and indirect tenderness, liver and spleen not palpable

Musculoskeletal: No inflammation and pain on both knees, no limitation of motion

Physical Exam Spine: Midline, No deformities along the

vertebra Pulse: full and equal on all extremities External genitalia: no clitoromegaly Tanner stage: Breast bud:2 Pubic Hair: 2

Physical Examination• Neurologic Examination

– Conscious, coherent, oriented to three spheres– Opens eye spontaneously, Oriented, Obeys

command– No anosmia– 20/40 on L and R eyes, (+) confrontation,

midline gaze, (+) direct and consensual light reflex, intact pupillary light reflex, (+) ROR

– EOMs full and equal– Can feel light touch equally on the forehead,

cheeks, mandibular area

Physical Examination• Neurologic Examination

– Can raise both eyebrows, can frown, smile, and can puff out both cheeks

– No hearing deficits, no lateralization– Uvula midline, rises on phonation– Can raise shoulder against resistance on

the left– Tongue midline on protrusion

Physical Examination• Neurologic Examination

– MMT 5/5 on all extremities– Can perform FTNT and APST– Sensitive to pain, temperature, light touch,

and vibration– DTRs ++ on all extremities, (-) Babinski

Salient Features 14 y/o, Female Sampaloc, Manila 4 day Fever Bifrontal Headache Vomiting (1 episode) (-) Epistaxis, Abdominal Pain, Dizziness, Gum Bleeding (+) Loss of appetite, Myalgia (-) Cough, Colds, Dysuria, Diarrhea Flushed skin with dry lips Good skin turgor (+) Tourniquet test No palatal petechiae

APPROACH TO DIAGNOSIS

A presenting manifestation pointing to the least number of diseases

Fever with Constitutional

Symptoms

Dengue Hemorrhagic FeverInfluenzaTyphoid FeverLeptospirosis

WORKING DIAGNOSIS Acute Viral Infection to r/o Dengue Fever

with probable signs

Dengue Influenza Typhoid Fever LeptospirosisCommon in

Southeast Asia – Philippines, Thailand, Singapore

In tropical areas, influenza occurs throughout the

year.

Prevalent in developing countries

Most cases in tropical

developing countries

Fever of 2-7 days(Biphasic Pattern)

Fever Acute Fever(Biphasic Pattern)

Acute fever(Biphasic Pattern)

Headache, retro-orbital pain,

arthralgia, rash, hemorrhagic

manifestations

Myalgia, headache, malaise,

nonproductive cough, sore throat, and

rhinitis

Anorexia, nausea, malaise, vomiting, jaundice

Lethargy, headache,

malaise, nausea, vomiting,

myalgia, petehial or purpuric rash

Rapid and weak pulses, narrow pulse pressure,

hypotension, cold clammy skin

In children, diarrhea may be a

feature.Tachycardia, signs

of mild volume depletion with dry

skin

Resembles AGE in young children

Bradycardia, hypotension, but

circulatory collapse

uncommon

Signs of plasma leakage – pleural effusion, ascites, hypoproteinemia

Regional lymphadenopathy

, splenomegaly

Conjunctival suffusion,

generalized lymphadenopathy

Diagnostic Plans Complete blood cell count with

Platelet

Complete Blood Count Hemoconcentration (hematocrit increased 20%) –

precedes shock Thrombocytopenia (platelet count <100 x 109/L) are

seen in dengue hemorrhagic fever or dengue shock syndrome and occur before defervescence and the onset of shock.

Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness

Lymphocytosis, with atypical lymphocytes, commonly develops before defervescence or shock.

• Monitor CBC at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever

Treatment PlansSupportive Paracetamol 500mg/tab, 1 tablet PO every 4

hours for temperature >38.5 Oral rehydration solution 75 replace losses

volume per volume Increase oral fluid intake (water, soups, juice,

milk) Bed rest

Treatment PlansSupportive: Avoid dark colored foods Watch out for warning signs (severe abdominal

pain, passage of black stools, bleeding into the skin or from the nose or gums, sweating, and cold skin )

Observe carefully for complications for at least 2 days after recovery from fever.

Treatment PlansPreventive1.) Prevent mosquito bites:

Wear full-sleeve clothes and long dresses to cover the limbs.

Use of mosquito repellents Use of mosquito nets to protect babies, old

people and others who may rest during the day.

Permethrin (pyrethroid insecticide) treatment on mosquito nets, curtains to repel or kill mosquitoes.

Treatment PlansPreventive2.) Prevent the multiplication of mosquitoes:

Mosquitoes which spread dengue live and breed in stagnant water in and around houses. Drain out the water from bottles, tanks, barrels, drums, buckets, etc.

All stored water containers should be kept covered at all times.

BRIEF DISCUSSION

Dengue Viral Replication Cycle Family Flaviviridae Genus Flavivirus Small, enveloped viruses containing a

single-stranded RNA genome of positive polarity

Vector: Aedes aegypti

Dengue Viral Replication Cycle Attachment to the cell surface Entry into the cytoplasm Translation of viral proteins Replication of the viral RNA genome Formation of virions (encapsidation) Release from the cell

Incubation Period Symptoms typically develop between 4

and 7 days (3-14 days)

DENGUE FEVER Acute febrile illness accompanied by:

Headache Retroorbital pain Marked muscle and joint pains - "break-bone fever“

Fever typically lasts for 5-7 days Some patients display a biphasic ("saddleback")

fever curve, with the second febrile phase lasting 1-2 days

The febrile period may also be followed by a period of marked fatigue that can last for days to weeks

DENGUE FEVER Constitutional symptoms

Fever and headache Eye pain Body pain Joint pain

Rash Gastrointestinal symptoms

Nausea or vomiting Diarrhea

Respiratory tract symptoms Cough Sore throat Nasal congestion

DENGUE FEVER Physical examination

Non-specific Fever Rash – macular or maculopapular Conjunctival injection, pharyngeal

erythema, lymphadenopathy, and hepatomegaly

DENGUE FEVER Laboratory findings

Leukopenia Thrombocytopenia Serum aspartate transaminase (AST) levels

are frequently elevated

Thank You.