Post on 10-Apr-2018
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By: Katrina Tugado and Jehrisse Soriano
Dengue Hemorrhagic Fever III
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Identifying data:
y D.A is a 6 year old Filipino male, Roman
Catholic born on September 2, 2003 from
Caloocan City admitted for the first time
on July 25, 2010
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Source and Reliability
y Parents, both with 85% reliability
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Chief complaint:y Fever of six days duration
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History of Present Illnessy 6 days PTA,yThe patient had intermittent undocumented
moderate grade fever, the patient was givenParacetamol syrup 250 mg/5 ml, 10 ml every four
hours (29 mkdose)yAccompanied by epigastric pain not relieved by food
intakeyThere were also five episodes of vomiting of
previously ingested food amounting to 2tablespoons/episodeyThere were no cough, colds, abdominal distention,
diarrhea noted and no consult was done
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History of Present Illness
y 5 days PTA,
yThere was persistence of undocumented moderate
grade fever
yEpigastric pain decreased in frequencyyVomiting was also noted to decrease, 3 episodes
were noted, composed of previously ingested food
amounting to 2 tbsps./ episode
y Paracetamol syrup 250 mg/5 ml, 10 ml every four
hours (29 mkdose) was continued
yNo changes in activity and appetite noted, no consult
was done
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History of Present Illness
y 3 days PTA,
y Intermittent undocumented moderate grade fever
persisted
yEpigastric pain and vomiting with the samecharacteristics as before persisted.
yNo cough, colds, bleeding and melena were noted
yConsult at Bermudez Polymedic Hospital was done
and the patient was admitted for 1 days
yCBC; PC was done which revealed:
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History of Present Illness7/23 (am) 7/23 (pm) 7/24 (am) 7/24 (pm)
Hgb 0.38 0.38 0.41 0.41
Hct 133 133 144 144
WBC 8.6
Segmenters 0.67
Lymphocytes 0.32
Monocytes 0.01
Eosinophils 0
P
latelets 320 314 256
220
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History of Present Illness
yUrinalysis and serum electrolytes were done but
results were unrecalled
y Impression was dengue fever and the patient wasadvised transfer to a tertiary hospital for further
evaluation and management.
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History of Present IIlness
y 1 day PTA,
yThe patient was transferred to Tala Hospital,
impression given was also Dengue fever. CBC was
done but with unrecalled results.yHe was also given unrecalled medications for
abdominal pain and was advised transfer to a
tertiary hospital hence transfer to NCH
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Past Health Maintenance History
y (-) PTB
y (-) pneumonia
y (-) asthma
y (-) chicken poxy (-) measles
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Gestational History
y The mother had no known feto-maternal complications
y No intake of medications/ x-ray exposure
y Regular PNCUs at 4 months until birth
y With regular intake of multivitamins and ferrous sulfate
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Birth History
y The patient was born full term via normal spontaneous
delivery at a lying-in clinic to a 26 year old G2P2 (2002)
mother.
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Neonatal history
y (+) spontaneous respiration
y (-) jaundice
y (-) convulsions
y (+) weight gain
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Feeding History
y Breastfed from 0-2 mos.
y Formula fed from 2 mos-1 year old (Nestogen (1:1))
y Started on solids at 7 mos.
y Previously with good appetitey Multivitamins started at birth until present (Tiki-tiki, Ceelin)
y Present diet: rice, fried chicken, pork
y (-) vomiting
y (-) food intolerance
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Developmental History
y Roll over at 6 mos.
y Sat alone at 6 mos.
y Stood alone at 12 mos.
y Walk alone at 15 mos.y Talked at 2 y.o.
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Immunization History
y 1 dose of BCG
y 3 doses of DPT
y 3 doses of OPV
y 3 doses of Hep By 1 dose of measles
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Family History
y Mother, 32 y/o apparently healthy
y Father, 37 y/o apparently healthy
y 8 y/o male sibling, with dengue fever
y (-) PTBy (-) DM
y (-) Asthma
y (-) Congenital defects
y (-) Mental retardation
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Physical examination
y General survey: awake,afebrile, coherent, not in
cardiorespiratory distress
y Vital signs: BP: 80/50 mmHg, CR: 118 bpm, RR: 30,
T: 36.6C
y Anthropometrics: Wt: 17 kgs. Ht: 103 cm
y HEENT: Anictric sclerae, pink palpebral sclerae, no
tonsillopharyngeal congestion, no
cervicolymphadenopathiesy Thorax and Lungs: Equal chest expansion,
decreased breath sounds at the lower lung fields
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y CVS: adynamic precordium, normal rate and rhythm,
no murmurs
y Abdomen: flat, soft, tenderness on the epigastric
area and right flank,NABS
y Extremities: poor pulses, CRT > 4 secs, cold
extremities
y Rectal exam: no skin tags, no fissure, with good
sphincter tone, empty rectal vault with yellowishmaterial upon withdrawal of the examiningfinger
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y Abdomen: flat, soft, tenderness on the epigastric area and
right flank, NABS
y Extremities: poor pulses, CRT > 4 secs, cold extremities
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Subjective data:
y Moderate grade undocumented fever
y Epigastric pain
y Vomiting
y A sibling with the same symptoms
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Objective data:
y Low Hgb
y Low Hct
y Decreasing platelet count (NV: 150-450 x 10 9 L)
y Tenderness of the epigastric are upon palpationy Poor pulses, CRT > 4 secs, cold extremities
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DHF vs. DFDengue fever Dengue Hemorrhagic fever
Symptoms: High fever, severe malaise,
headache, retroorbital pain, myalgia,
lumbosacral pain, accompanied by sore
throat, nausea, vomiting, epigastric pain and
diarrhea
(in children: abdominal pain and sore throat
are predominant)
Same with DF in the early phase of illness
Usually with high fever, hemorrhagic
phenomena, hepatomegaly, circulatory
failure
Defervescence: 3-8 days usually followed by
minor hemorrhagic phenomena, others may
progress to severe GI bleeding and shock
Defervescence: 2-5 days
Simultaneous or sequential introduction of
two or more serotypes,
Presents with thrombocytopenia (
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Dengue Hemorrhagic fever
y Hepatic enlargement and tenderness is a sign of bad
prognosis.
y Other manifestations include pleural effusion and
hypoalbuminemia, encephalopathy with normalcerebrospinal fluid.
y Diffuse capillary leakage of plasma is responsible for the
hemoconcentration
y
Thrombocytpenia + hemoconcentration
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Prognosis:
y The case-fatality of DHF/DSS is 10% or higher if
untreated.
y With supportive treatment, fewer than 1% of such
cases succumb.y Recovery is rapid and without sequelae
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WHO classification:
y Grade I - thrombocytopenia + hemoconcentration.
Absence of spontaneous bleeding.
y Grade II - thrombocytopenia + hemoconcentration.
Presence of spontaneous bleeding.
Grade III - thrombocytopenia + hemoconcentration.
Hemodynamic instability: filiform pulse, narrowing of
the pulse pressure (< 20 mmHg), cold extremities,
mental confusion.
Grade IV - thrombocytopenia + hemoconcentration.
Declared shock, patient pulseless and with arterial
blood pressure = 0 mmHg (dengue shock syndrome
- DSS).
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Differentials:
y Leptospirosis:
y Ruled in:
y Fever, abdominal pain, vomiting of six days duration
y
Malariay Ruled in:
y Daily fever presentation
y Ruled out:
y Spleen enlargement
y Jaundice