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CLINICAL MANAGEMENT

CONFERENCE



CLINICAL HISTORY

General Data

J.T. , 20-year-old female, single

Filipino, Catholic

Born on Oct 11, 1990 in Quezon City

Currently residing in Salitran, Dasmarinas,Cavite

Admitted last Aug 24, 2011 at around 5:26 pm



Chief Complaint

Fever



HISTORY OF PRESENT

ILLNESS

4 days PTA ± Day 1 of Fever

(+) fever - 38.6 °C

No vomiting, diarrhea, body pains ,

cough and colds were noted

(+) intake of Paracetamol 500mg /tablet

1 tablet every 4 hours temporary relief of fever = 37.3 °C

Good oral fluid intake and urine output



HISTORY OF PRESENT

ILLNESS

3 days PTA ± Day 2 of Fever

(+) fever persisted = 38 °C (+) generalized weakness

no vomiting, diarrhea, body painswhere noted

Took Paracetamol 500mg every 4hours ± temporary relief of fever

No cough and colds noted



2 days PTC ± Day 3 of Fever

(+) fever persisted ± 38 °C

(+) generalized weakness

no vomiting, diarrhea, body pains wherenoted

Took Paracetamol 500mg every 4 hours ± temporary relief

No cough and colds noted



1 day PTA ± Day 4 of Fever

(+) persistence of fever, remittent± 38-39.2C

(+) rashes ± flat, erythematous, non-pruritic onboth upper extremities

(+) generalized weakness

no vomiting, diarrhea, body pains where noted

Took Paracetamol 500mg every 4 hours ± slightrelief (goes down .5-1 C)

This prompted the patient to seek medicalconsult



PAST MEDICAL

HISTORY

(-) hypertension

(-) diabetes mellitus (-) bronchial asthma

(-) known allergies

Immunization History

BCG, DPT3, OPV3, Hepa B3,

MMR1



Family History

(+)HPN ± mother

(+)DM ± Father, mother

(-)asthma

(-)allergies



Personal/ Social history

Non smoker

Non Alcoholic beverage drinker

No food preference

Recently graduated as a Nurse

Lives near a creek

Has history of travel to Bicol 1 month

PTC



OB-GYN History

G0P0

LNMP : 8/22/2011

Regular 28-day cycle

Lasting 2-3 days 3-4 pads/day

(+)dysmenorrhea



REVIEW OF SYSTEMS

General

(-) weight loss/ weight gain

Skin

(-) dryness, (+) itchiness

HEENT

(-) headache, (-) eye pain, (-) changes in

vision, (-) hearing loss, (-) ringing in ears, (-

)epistaxis, (-) nasal discharge, (-) dysphagia



REVIEW OF SYSTEMS

CVS

(-) chest pain, (-) palpitations, (-) shortness of breath, (-) orthopnea, (-) paroxysmalnocturnal dyspnea

Chest and Lungs

Shortness of breath, (-) pain, (-) sputum

GI

(-) heartburn, (-) diarrhea, (-) constipation, (-) hematemesis, (-) hematochezia, (-) melena



REVIEW OF SYSTEMS

Urinary

(-) nocturia, (-) dysuria, (-) hematuria

Peripheral Vascular

(-) claudication, (-) cramping

Musculoskeletal

(-) muscle or joint pain, (-) cramps, (-) limited

range of motion



REVIEW OF SYSTEMS

Neurologic

(-) loss of consciousness, (-) numbness, (-) tingling

Hematologic

(-) easy bruising or bleeding

Endocrine

(-) increased thirst, (-) increased urination, (-)

heat or cold intolerance



PHYSICAL

EXAMINATION

General Survey

conscious, coherent, oriented to time placeand person, not in cardiorespiratory distress

BP: 110/80 HR:90 RR: 18 Temp: 37.3 °C



Integument

(+) rashes ± flat, pruritic, erythematous macules

on the upper extremities and on the thighs

(-) pallor, (-) jaundice, (-) edema, afebrile, moistwith good skin turgor

hair is black in color, (-) hair loss

(-) nail plate dystrophy, (-) change in shape, (-) color changes

(-) nail bed color changes, (-) primary or secondary lesions



HEENT

Head and Neck symmetrical head, (-) mass, (-) tenderness

(-) cervical lymph node enlargement

midline trachea

thyroid gland not palpable, no tenderness

- thyroid (cartilage) prominence moves withdeglutition

- full and equal carotid pulses, (-) carotidbruits



Eyes

(+) symmetrical with pink conjunctiva, 3-4mm

EBRTL (+) clear cornea, (+) intact visual fields, full

extraocular muscle movement

Ears

pinna is mobile

(-) masses, ulcerations or tenderness

periauricular areas likewise have no swelling or tenderness

canal is patent, (-) masses, (-) discharge



Nose

external nose is symmetrical

aligned vertically with the midline

(-) masses, (-) deformities or tenderness



Oral Cavity and Oropharynx

- symmetrical lips, pinkish, devoid of massesor ulcerations

- oral mucosa and gums are smooth, pink

-(-) lesions, masses or ulcerations

- teeth are complete and devoid of caries,

stains or plaques

- uvula and palate symmetrically rises



Chest and Lungs

Inspection: symmetrical chest w/ symmetricalchest expansion, (-) chest deformity, (-) intercostal space retractions, (-) masses, APdiameter = 2:1

Palpation: equal tactile fremitus

Percussion: Resonant on all lung fields

Auscultation: equal bronchial andbronchovesicular breath sounds, (-) cracklesor wheezes



Cardiovascular

Inspection: (-) precordial bulge

Palpation: (-) heaves, (-) thrills, apex beat at

the 5th ICS left anterior axillary line

Auscultation: normal rate, regular rhythm



Abdomen

Inspection: flat, (-) visible veins, (-) discoloration, pulsations nor peristalsis

Auscultation: bowel sounds low-pitched,

normoactive, (-) bruit, (-) friction rub

Palpation: soft, (-) tender, (-)murphy¶s sign

Percussion: tympanitic on all quadrants, liver

span is 7cm



Extremities

General: (-) joint pains, (-) difficulty indressing and walking, able to get out of bed,

full and equal peripheral pulses, no atrophy

TMJ: (-) redness, mass, swelling, deformity,

tenderness, crepitus nor limitation of motion

Extremities: (-) tenderness, (-) edema



Neurologic Examination

Mental Status Examination

- awake, conscious, responsive, normal

stream of talk

- appropriate mood, normal attention span

- oriented to time, place, and person, does

not present with auditory and visual

hallucinations



Cranial Nerves

Cranial Nerve I ± no anosmia

Cranial Nerve II ± 2-3 mm EBRTL

Cranial Nerve III, IV, VI ± intact EOM¶s

Cranial Nerve V ± good masseter tone

Cranial Nerve VII - no facial asymmetry

Cranial Nerve VIII ± intact gross hearing

Cranial Nerve IX, X± intact gag reflex



Cranial Nerve XI ± good shoulder shrug

Cranial Nerve XII ± tongue is at the midline



Motor: 5/5 in all extremities

Sensory: 100% sensation in all extremities

Cerebellar Exam

- (-) nystagmus, (-) dysmetria, (-)

dysdiadokinesia



DIAGNOSTICS /LABORATORY

EXAMS



URINALYSIS

(8/24/2011)

Yellow, clear, 1.010, pH 6.0, (-) albumin, (-)

sugar

0-1 WBC/HPF, 0-1 RBC/HPF

Few epithelial cells, few mucus threads



COMPLETE BLOOD

COUNT

Test Reference 8/23 8/24 8/25

Hgb 123-153

G/L

135 134 116

Hct 0.36-0.45 0.41 0.41 0.36

WBC 4.2-5.4 2.6 2.4 2.6

Segs 0.36-0.66 0.64 0.58 0.19

Lymph 0.22-0.40 0.31 0.37 0.70

Eosino 0.01-0.04 0.02 0.01 0.05

Mono 0.04-0.08 0.01 0.03 0.03

Platelet 150-450 248 210 202



DIAGNOSTICS

0

50

100

150

200

250

300

Day 3 Day 4 Day 5

Hemoglobin

Hematocrit

WBC

Platelet



DIAGNOSTICS

(8/24/2011)

Test Results Reference Range

Blood Urea Nitrogen 1.30 L 2.50-7.10 mmol/L

Serum Creatinine 55.00 46.00-92.00 mmol/L

Sodium 145.00 137.00-145.00

mmol/L

Potassium 3.40 L 3.50-5.10



SEROLOGY FOR DENGUE

TEST

D AY 5 OF FEVER (8/24/2011)

Interpretation of

Result

IgM Positive Primary Dengue Infection

IgM and IgG Positive Secondary Dengue Infection

IgG Positive Secondary Dengue Infection

IgM NegativeIgG Positive

R L



RUMPEL-LEEDE

C APILLARY FRAGILITY

TEST (TOURNIQUET TEST)



DIAGNOSIS

Dengue, Non-Severe, with Warning Sign

Basis:

Living in an endemic area

Fever

Rash

Generalized weakness Positive tourniquet test

Decreasing platelet count

Lethargy



DIFFERENTIAL DIAGNOSES



T YPHOID FEVER

RULE IN RULE OUT

High grade fever Cannot be ruled out

Body malaise

Rashes

Leukopenia

is a common worldwide illness, transmitted by the

ingestion of food or water contaminated with the feces of an

infected person, which contain the bacterium S almonella

enterica, serovar Typhi

Typhoid fever is characterized by a slowlyprogressive fever as high as 40 °C, profuse sweating

and gastroenteritis

a rash of flat, rose-colored spots may appear



MEASLES

RULE IN RULE OUT

High grade fever Absence of three Cs of

measles ± Coryza, cough,conjunctivitis

Generalized macupopapular

erythematous rash

also known as rubeola or morbilli, is an infection of the

respiratory system

Symptoms include fever, cough, runny nose, red eyes and a

generalized, maculopapular, erythematous rash.



CASE D ISCUSSION:

EPIDEMIOLOGY AND TRANSMISSION



DENGUE

EPIDEMIOLOGY

Most rapidly spreading mosquito-borne viral

disease in the world

An estimated 50 million dengue infections

occur annually and approximately 2.5 billion

people live in dengue endemic countries



DENGUE CASE CLASSIFICATION



1997 WHO CASE

CLASSIFICATION



NON-SEVERE DENGUE

WITHOUT W ARNING SIGNS

Pr obable dengue:

live in /travel to dengue endemic area

Fever and 2 of the following criteria:

Nausea, vomiting

Rash

Aches and pains

Tourniquet test positive

Leukopenia

Labor atory-c onfi rmed dengue

(important when no sign of plasma leakage)



DENGUE WITH W ARNING

SIGNS

Abdominal pain or tenderness

Persistent vomiting

Clinical fluid accumulation

Mucosal bleed

Lethargy, restlessness

Liver enlargement >2 cm Laboratory: increase in HCT concurrent with

rapid decrease in platelet count

*requiring strict observation and medical intervention



SEVERE DENGUE

should be considered if the patient is from an area of

dengue risk presenting with fever of 2±7 days plus any of

the following features:

Severe plasma leakage, leading to:

Shock

Fluid accumulation with respiratory distress

Severe bleeding, as evaluated by clinician

Severe organ impairment

Liver: AST or ALT 1000

CNS: impaired consciousness

Heart and other organs



TRANSMISSION



THE VIRUS

A small single-stranded RNA virus

comprising four distinct serotypes (DEN-1 to

-4).

These closely related serotypes of the

dengue virus belong to the genus Flavivirus,

family Flaviviridae.



THE VECTORS

The various serotypes of the dengue virus aretransmitted to humans through the bites of infected Aedes mosquitoes, principally Ae.

aegypti. A tropical and subtropical species widely

distributed around the world

The immature stages are found in water-filled

habitats, mostly in artificial containers closelyassociated with human dwellings and oftenindoors.

Aedes albopictus, Aedes polynesiensis andseveral species of the Aedes scutellaris



THE HOST

Incubation period: 4-10 days

Most infections are asymptomatic or subclinical.

Primary infection is thought to induce lifelong

protective immunity to the infecting serotype.

Individuals suffering an infection areprotected from clinical illness with a different

serotype within 2-3 months of the primary

infection but with no long-term cross-

protective immunity.



THE HOST

The dengue virus enters via the skin while aninfected mosquito is taking a bloodmeal.

During the acute phase of illness the virus is

present in the blood and its clearance from thiscompartment generally coincides withdefervescence.

Humoral and cellular immune responses areconsidered to contribute to virus clearance via the

generation of neutralizing antibodies and theactivation of CD4+ and CD8+ T lymphocytes.

In addition, innate host defence may limit infectionby the virus. After infection, serotypespecific andcross-reactive antibodies and CD4+ and CD8+ T

cells remain measurable for years.



Thrombocytopenia may be associated with

alterations in megakaryocytopoieses by the

infection of human haematopoietic cells andimpaired progenitor cell growth, resulting in

platelet dysfunction (platelet activation and

aggregation), increased destruction or

consumption (peripheral sequestration and

consumption).



TRANSMISSION OF THE

DENGUE VIRUS

Dengue virus circulating in the blood of

viremic humans is ingested by female

mosquitoes during feeding.

The virus then infects the mosquito mid-gut

and subsequently spreads systemically over

a period of 8-12 days.



After this extrinsic incubation period, the

virus can be transmitted to other humans

during subsequent probing or feeding.

The extrinsic incubation period is influenced

in part by environmental conditions.

Thereafter the mosquito remains infective for

the rest of its life.



CLINICAL MANAGEMENT AND

DELIVERY OF CLINICAL SERVICES



THE COURSE OF DENGUE

ILLNESS



I. FEBRILE PHASE

Patients typically develop high-grade fever

suddenly.

Usually lasts 2±7 days

Often accompanied by facial flushing, skin

erythema, generalized body aches, myalgia,

arthralgia and headache.

Some patients may have sore throat, injected

pharynx and conjunctival injection.

Anorexia, nausea and vomiting are common.



F E BRILE P HASE

Difficult to distinguish dengue vs non-dengue

febrile diseases in the early febrile phase

A positive tourniquet test in this phase

increases the probability of dengue.

Mild hemorrhagic manifestations like

petechiae and mucosal membrane bleeding

(e.g. nose and gums) may be seen.



Massive vaginal bleeding (in women of

childbearing age) and gastrointestinal bleeding

may occur during this phase but is not common .

The liver is often enlarged and tender after a few

days of fever .

The earliest abnormality in the full blood count is a

progressive decrease in total white cell count,

which should alert the physician to a highprobability of dengue.



II. CRITICAL PHASE

Around the time of defervescence

the temperature drops to 37.5±38C or less and

remains below this level

usually on days 3±7 of illness,

an increase in capillary permeability in parallel with

increasing hematocrit levels = the beginning of the

critical phase.

The period of clinically significant plasma leakage

usually lasts 24±48 hours.



C RITI C AL P HASE

Progressive leukopenia followed by a rapid decrease

in platelet count usually precedes plasma leakage.

At this point patients without an increase in capillary

permeability will improve, while those with increased

capillary permeability may become worse as a result

of lost plasma volume.



C RITI C AL P HASE

The degree of plasma leakage varies. Pleural effusion

and ascites may be clinically detectable depending on

the degree of plasma leakage and the volume of fluid

therapy.

Hence chest x-ray and abdominal ultrasound can be

useful tools for diagnosis. The degree of increase

above the baseline hematocrit often reflects the

severity of plasma leakage.



Those who improve after defervescence are

said to have non-severe dengue.

Some patients progress to the critical phaseof plasma leakage without defervescence

and, in these patients, changes in the full

blood count should be used to guide the

onset of the critical phase and plasma

leakage.



III. RECOVERY PHASE

If the patient survives the 24±48 hour criticalphase, a gradual reabsorption of extravascular compartment fluid takes place in the following48±72 hours.

General well-being improves, appetite returns,gastrointestinal symptoms abate, hemodynamicstatus stabilizes and diuresis ensues.

Some patients may have a rash of ³isles of white

in the sea of red´

Some may experience generalized pruritus.Bradycardia and electrocardiographic changesare common during this stage.



CLINICAL PROBLEMS IN THE



DIFFERENT PHASES OF

DENGUE

1 Febrile phase Dehydration; high fever may cause

neurological disturbances and febrile

seizures in young children

2 Critical Phase Shock from plasma leakage; severe

haemorrhage; organ impairment

3 Recovery

phase

Hypervolemia (only if intravenous fluid

therapy has been excessive and/or

has extended into this period)



SEVERE DENGUE

Defined by one or more of the following:

plasma leakage that may lead to shock

(dengue shock) and/or fluidaccumulation, with or without

respiratory distress, and/or

severe bleeding, and/or

severe organ impairment



Progression of vascular permeability

worsening of hypovolemia

Initial stage of shock

Compensatory mechanism produces tachycardia

and peripheral vasoconstriction reduced skin

perfusion cold extremities and delayed

capillary refill time



The patient is considered to have shock

If the pulse pressure is equal or less than 20

mmHg in children

He/she has signs of poor capillary perfusion

Cold extremities, delayed capillary refill, rapid

pulse rate



Severe dengue should be considered if the patientis from an area of dengue risk presenting withfever of 2±7 days plus any of the followingfeatures:

There is evidence of plasma leakage, such as:

high or progressively rising hematocrit;

pleural effusions or ascites;

circulatory compromise or shock (tachycardia,cold and clammy extremities, capillary refill timegreater than three seconds, weak or undetectable pulse, narrow pulse pressure or, inlate shock, unrecordable blood pressure).



There is significant bleeding.

There is an altered level of consciousness(lethargy or restlessness, coma, convulsions).

There is severe gastrointestinal involvement(persistent vomiting, increasing or intenseabdominal pain, jaundice).

There is severe organ impairment (acute liver

failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations,cardiomyopathy) or other unusualmanifestations.



RECOMMENDATIONS FOR

TREATMENT

A STEPWISE APPROACH IN



THE MANAGEMENT OF

DENGUE

Step 1 Overall assessment

Step 2

Diagnosis, assessment of disease phase and severity

Step 3 Management

STEP 1: OVERALL



STEP 1: OVERALL

ASSESSMENT

History

date of onset of fever/illness;

quantity of oral intake;

assessment for warning signs (Textbox C);

diarrhoea;

change in mental state/seizure/dizziness;

urine output (frequency, volume and time of last voiding);

other important relevant histories, such asfamily or neighborhood dengue,



HISTORY

Parameters Patient

Date of onset of fever/illness 5 days PTC

Quantity of Oral Intake >2L of water/day

Assessment of Warning signs Abdominal Pain

Ongoing vomiting

Liver enlargement

Mucosal bleeding

High hematocrit with lowplatelets

Lethargy



HISTORY

Parameters Patient

Change in mental state NONE

Urine Output Patient claims to have nochanges in urination. (-)

anuria (-) dysuria

(-)dribbling



36.837

37.2

37.437.637.8

3838.238.438.6

38.8

Day 1Day 2Day 3Day 4Day 5Day 6

Temperature

Temperature

STEP 1: OVERALL



STEP 1: OVERALL

ASSESSMENT

History ( continued)

travel to dengue endemic areas, co-

existing conditions (e.g. infancy,pregnancy, obesity, diabetes mellitus,

hypertension),

jungle trekking and swimming in waterfall

(consider leptospirosis, typhus, malaria),

Recent unprotected sex or drug abuse

(consider acute HIV seroconversion

illness).

STEP 1: OVERALL



STEP 1: OVERALL

ASSESSMENT

Physical Examination

assessment of mental state;

assessment of hydration status;

assessment of hemodynamic status

(Textbox D);

checking for tachypnea/acidoticbreathing/pleural effusion;

STEP 1: OVERALL



STEP 1: OVERALL

ASSESSMENT

Physical Examination

checking for abdominal

tenderness/hepatomegaly/ascites;

examination for rash and bleeding

manifestations;

tourniquet test (repeat if previouslynegative or if there is no bleeding

manifestation).



PHYSICAL EXAMINATION

Parameters Patient

Assessment of Mental

state

Patient is awake, conscious,

coherent; Oriented to time person

and place;

Assessment of

Hydration status

(-) pallor; (-) pale palpebra; (-) dry oral

mucosa

Checking for

tachypnea/acidotic

breating/ pleural effusion

Patient had normal breathing rate and

pattern; Breath sounds were clear in

both lung fields; Vocal fremitus wereresonant in both dull fields;

Symmetrical chest expansion



Parameters Patient

Examination of Rash

and Bleeding

manifestations

Generalized macular rashes on

patient¶s upper and lower

extremities, chest, and backTourniquet Test

STEP 1: OVERALL



STEP 1: OVERALL

ASSESSMENT

Investigation

CBC with platelet count on first visit

Other tests

Liver function test

Glucose

Serum electrolytes

Urea and creatinine

Bicarbonate or lactate

Cardiac enzymes

ECG

Urine specific gravity

TREATMENT ACCORDING



TREATMENT ACCORDING

TO GROUPS A-C

Group A

patients who may be sent home

able to tolerate adequate volumes of oral

fluids and pass urine

at least once every six hours, and do not

have any of the warning signs, particularly

when fever subsides

TREATMENT ACCORDING



TREATMENT ACCORDING

TO GROUPS A-C

Group B

Patients who should be referred for in-hospital management

patients with warning signs

those with co-existing conditions that maymake dengue or its management morecomplicated

pregnancy, infancy, old age, obesity,

diabetes mellitus, renal failure, chronichaemolytic diseases),

those with certain social circumstances (suchas living alone, or living far from a healthfacility without reliable means of transport).

TREATMENT ACCORDING



TREATMENT ACCORDING

TO GROUPS A-C

Group C

patients who require emergency treatment and

urgent referral when they have severe dengue

All patients with severe dengue should be

admitted to a hospital with access to intensive

care facilities and blood transfusion. Judicious

intravenous fluid resuscitation is the essential and

usually sole intervention required.



MANAGEMENT IN THE



M ANAGEMENT IN THE

ER

CBC with Platelet Count

Advised Admission

MANAGEMENT IN THE



M ANAGEMENT IN THE

W ARDS

Diet as tolerated

Monitor VS q4, I and O q shift and record

IVF: D5LR 1L x 8 hours

Diagnostics:

CBC with PC

Na, K, BUN, Crea

CBG = 110

CXR, UA

Salmonella IgG, IgM

Dengue Blot Test

T



THERAPEUTICS

Paracetamol 500 mg/tablet 1 tablet q4 for T

> or = to 37.8C

Paracetamol 300 mg IV q4 for T>38.5C

Multivitamins capsule OD

R



REFERENCE

WHO Dengue Guidelines for Diagnosis,

Treatement, Prevention and Control 2009

dengue power pointed it

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