Post on 07-Aug-2018
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Case Presentation:
DengueBy Michael B. Valderrama
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Objectives To present a case of Dengue Fever with
warning signs
To be able to discuss the dierentials!pathophysiology! clinical manifestations andprognosis of a patient with dengue withwarning signs
To be able to discuss the appropriatemanagement of a patient with dengue feverwith warning signs
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"eneral Data #$D%! &'yo! M
(oman )atholic
FilipinoMontalban! (i*al
+dmitted on, #une - '&/
+ccompanied by the Father! (eliability -0
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)hief )omplaintFever and Vomiting
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1istory of the 2resent
3llnessFive days prior to admission!3ntermittent! undocumented fever
relieved by paracetamol 4'/ mg5%o vomiting! no cough and colds! and no loose
stools.
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1istory of the 2resent
3llnessTwo days prior to admission,6till with no cough and colds! no vomiting and no
loose stoolsFever persisted
%ow with accompanying abdominal pain in theepigastric area with no radiation to surrounding areas.
)onsult sought at 7nares 1ospital
)B)41gb, &&'! 1ct, .'8! 9B), :.8! 2latelets, &'/5.Initial Diagnosis: Urinary tract infection
prescribed )efale;in 4unrecalled dose5 andparacetamol '/ mg before discharge.
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1istory of the 2resent
3llnessOne day prior to admission!Fever and epigastric pain still persisted
%ow with accompanying vomiting of threeepisodes! &cc
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1istory of the 2resent
3llnessOn te day of admission,Fever! epigastric pain and vomiting were
persistent which prompted consult.6till with no coughs and colds! and loose stools.
)B) was ordered at the 2)M) 41gb, &=>! 1ct,=:! 9B), /.'! 2latelets, ?85.
+dvised admission
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Temporal 2ro@le
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!eview of "edications and #abs%o medications! vitamins and herbal
supplements
)B) from 7nares 1ospital, 41gb, &&'! 1ct,.'8! 9B), :.8! 2latelets, &'/5.
)B) from 2)M), 41gb, &=>! 1ct, =:! 9B), /.'!2latelets, ?85.
(ising 1ct! decreasing platelet count.
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(eview of 6ystems
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2ast Medical 1istory%o history of +sthma! allergies! and primary
comple;.
2revious 1ospitali*ations'/ for $cute gastroenteritis
2revious 6urgeries'= for incision and drainage of a %ec&
abscess • There are no Anown allergies to food and
medications.
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Family 1istory There is no 1istory of Malignancies! DM! 1T%!
+topy
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Family "enogram
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%utritional 1istoryBreastfeeding, Birth until &./ years
Formula 4%estogen! Bona5 until > years.
)omplementary feeding at / months.
'= hour diet recall,(ice and adobo for breaAfast
(ice and porA sinigang for lunch
fried @sh and mongo for dinner.
Morning snacA was bread and milA.
• 2reference for chicAen! porA! beef and suash andregularly consumes softdrinAs and junA food forsnacAs.
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Birth and Maternal
1istory2reterm 4unrecalled +O"5 to a '/ year old
":2' 4'&'5
%onCsmoAer! nonCdrinAer! regular prenatalchecACups starting & month
)aesarean 6ection by an OBC"7% in ahospital.
Birth weight and height was unrecalled+2"+(, good cry after delivery.
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Birth and Maternal
1istoryMother tooA unrecalled Multivitamins
Maternal complications, preCecplamptic duringdelivery
Vitamin E and eye care
%ewborn screening done
Baby noted to jaundiced
resolved after one weeA.
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3mmuni*ation 1istoryB)" 4&5! D2T 4:5! O2V 4:5! 1iB 4:5! 1epB 4=5!
MM( 4'5! measles 4&5
(otavirus 45! 2neumococcal 45! 3nuen*a 45Varicella 45! 1ep + 45 and Typhoid 45.
1e has not yet had boosters for 1ep B! DTa2!and MM(
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Developmental 1istory(ross motor: )an stand on his own at &
months! walA up stairs alone at 'yrs
Fine $daptive: MaAes circular stroAes at '
#anguage: Enows name and se;! most ofspeech intelligible to strangers at :yrs.
)ocial: 2arallel play and helps in dressing at
: yrs
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Developmental 1istoryat par with age! with no noted delay in gross
motor! @ne adaptive! social and languagedevelopmental milestones.
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2ersonal! 6ocial and Gnvironmental
1istoryDwelling, one storey! twoCbedroom! concrete
house with adeuate ventilation
6i;Cmember household
+ccess to electricity
2otable water from a re@lling station
%o e;posure to environmental to;ins!
bioha*ards and tobacco."arbage collection, three times a weeA!
unsegregated
%o history of recent travel.
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1GG+D666Home:1ome life is happy
2arents provide for the needs of the family
2atient e;pressed love and respect for theparents and his sibling.
Occasional disciplinary spanAing
(ules are fairly strict especially in academics2arents can be relied upon when having a
problem
%o recent major changes in the family
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1GG+D666Education: The child is in grade >
elementary! a consistent honor student and iscurrently top & of his class. 1e was not bullied
by classmates or other children in thecommunity.
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1GG+D666Education:"rade > elementary
)onsistent honor student
)urrently top & of his class.
Favorite subject, 6cience
"ets along well with teachers and classmates
1e is not bullied by classmates or other childrenin the community.
%o goals
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1GG+D666Eating Behavior 2reference for chicAen! porA! beef and suash
and regularly consumes softdrinAs and junA
food for snacAs*specially li&es fried cic&en and
amburgers
%o diets
)ees self as tin
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1GG+D666 Activity HiAes to play basAetball and tumbang preso
with friends and classmates
6pends about ' hours browsing social mediaduring holidays and weeAends. %one duringschool days
TV, & hour everyday
1as a male bestfriend in his class.
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1GG+D666Drugs1as no friends who smoAe! drinA or tried drugs
1as not tried drugs himself, fears parents
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1GG+D666Sexuality 3nterested in opposite se;! but has no crushes
or girlfriends
%o forced or uncomfortable se;ual e;periences.
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1GG+D666Suicide and Depression1as no suicidal ideations
Does not hurt himself
Financial situation of family maAes him sad
6leeps well
Vents anger or sadness through crying
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1GG+D666Safety %ot a member of a gang or fraternity
+ccompanied by the mother or father going toand from school
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1GG+D666Spirituality (oman )atholic
Believes in "od
2rays at night but does not go to churchregularly
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)ta&eolders+ $nalysis
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2hysical G;amination(eneral $ppearance+waAe! alert! and not in cardiorespiratory
distress. 9eaAClooAing.
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2hysical G;amination9eight, :=Ag
1eight, &=cm
BM3 &8.:1F+, between C& and C' 4%ormal5
BM3F+, between and C& 4%ormal5
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2hysical G;aminationVitals Signs: B2, ? 1(, >? bpm ((, &'
bpm T, :>./ )
Head and Neck : %ormocephalic! ushedface! %o )H+D6! %o necA vein engorgement.%o lesions in scalp
Eyes: +nicteric sclerae! 2inA palpebral
conjunctivae! %o eye discharge! %o periorbitaledema! %o matting of eyelashes! Gyes arebrisAly reactive to light! 4I5 (ed orange ree;.
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2hysical G;aminationEars: Gars are symmetric. Gar canal is nonC
hyperemic and tympanic membrane is notbulging. %o tragal tenderness. Visible cone of
light bilaterally! with brownish retainedcerumen partially occluding the ear canalsbilaterally.
Nose: %asal Bridge is at! no alar aring!nasal septum is midline! and turbinates arepinA with no watery nasal discharge.
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2hysical G;aminationral !avity: Dry lips! moist oral mucosa!
hyperemic buccal mucosa and pharyngealwalls. %o tonsilar enlargement. Dental carries
present. %o gingival and mucosal lesions.
!ardiovascular: +dynamic precordium! %oheaves no thrills! (egular cardiac rate andrhythm! Distinct heart sounds s&Js' at thebase! +pe; beat at the =th 3)6 M)H! %omurmurs appreciated.
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2hysical G;amination!hest and "ungs: 6ymmetric chest
e;pansion! %o retractions! %o lesions ormasses. )lear breath sounds
Back and Spine: %o lesions and obviousspinal deformities.
A#domen: Flat abdomen! no distention! no
scars! no masses! normoactive bowel soundsand tympanitic on all uadrants! withepigastric tenderness 4pain scaleK /
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2hysical G;amination$elvis and %& tract: %
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6alient Features
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2hysical G;amination
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2hysical G;amination
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Primary or&ing ImpressionDengue Fever wit arning signs-vomiting and abdominal pain.'
6ymptom presentation +bsence of hemorrhagic symptoms
3nitial and follow up )B) 4rising haematocrit /C&0! leuAopenia
L/cells
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Patopysiology of
Dengue(ecovery from infection by one provideslifelong immunity against that particularserotype.
)rossCimmunity to the other serotypes afterrecovery is only partial and temporary.
6ubseuent infections by other serotypesincrease the risA of developing severe dengue.
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Patopysiology of
Dengue9arning signs occur :8 days after the @rstsymptoms in conjunction with a decrease intemperature 4below :-P)
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)ourse of 3llness
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DiagnosisVirus isolation serotypic days and ifprocessed without delay
Viral nucleic acid detection
CDengue genome detection using (TC2)(
Viral antigen detection 4%6&5CDeclines to undetectable levels at day /C>.
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Diagnosis3mmunological response based tests 3gM and 3g" antibodyassayssimple and rapid test based on detecting the dengueCspeci@c
3gM antibodies in the test serum using antiChuman 3gM
+nalysis for haematological parametersTrombocytopenia! a drop in platelet count below &
per Ql! is usually found between the third and eighth day ofillness often before or simultaneously with changes in
haematocrit./aemoconcentration with an increase in the haematocrit of
'0 or more is considered to be a de@nitive evidence ofincreased vascular permeability and plasma leaAage.
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Diagnosis
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Therapeutics Treatment of uncomplicated dengue fever is)upportive'
$ntipyretics should be used to Aeep bodytemperature L=P) 4&=PF5.+spirin is contraindicated
Fluid and *lectrolyte !eplacement
reuired for de@cits caused by sweating!fasting! thirsting! vomiting! and diarrhea.
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2rognosis"ood but care should be taAen to avoid use ofdrugs that suppress platelet activity.
3n dengue hemorrhagic fever! Death hasoccurred in =C/0 of patients with shocA! butwith adeuate intensive care! deaths shouldoccur in L&0 of cases.
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2reventive Measures and 2ublic
1ealth 3ssues+voidance of daytime householdCbased
mos0uito bites'3nsecticides! repellents! body covering with
clothing! screening of houses! and destruction of A.aegypti breeding sites.
9ater should not be stored for long periods oftime to prevent it from becoming mosuito
breeding sites.Harvaecides can be used in stored drinAing water.
Vaccines are not yet available but are currentlyunder development.
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2rogress %otes
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2rogress %otes
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(eferences!eferences:Eliegman et. al. 4'&&5 Nelson’s Textbook of
Pediatrics! &?th edition
9orld 1ealth Organi*ation. '&&.Comprehensive guidelines for prevention andcontrol of dengue and dengue haemorrhagicfever. Revised and expanded edition. 91O,(egional ORce for 6outhCGast +sia.
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Tan& you1