Post on 06-Apr-2018
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CLINICAL MANAGEMENT
CONFERENCE
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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
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Chief Complaint
Fever
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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
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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
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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
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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
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PAST MEDICAL
HISTORY
(-) hypertension
(-) diabetes mellitus (-) bronchial asthma
(-) known allergies
Immunization History
BCG, DPT3, OPV3, Hepa B3,
MMR1
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Family History
(+)HPN ± mother
(+)DM ± Father, mother
(-)asthma
(-)allergies
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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
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OB-GYN History
G0P0
LNMP : 8/22/2011
Regular 28-day cycle
Lasting 2-3 days 3-4 pads/day
(+)dysmenorrhea
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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
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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
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REVIEW OF SYSTEMS
Urinary
(-) nocturia, (-) dysuria, (-) hematuria
Peripheral Vascular
(-) claudication, (-) cramping
Musculoskeletal
(-) muscle or joint pain, (-) cramps, (-) limited
range of motion
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REVIEW OF SYSTEMS
Neurologic
(-) loss of consciousness, (-) numbness, (-) tingling
Hematologic
(-) easy bruising or bleeding
Endocrine
(-) increased thirst, (-) increased urination, (-)
heat or cold intolerance
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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
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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
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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
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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
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Nose
external nose is symmetrical
aligned vertically with the midline
(-) masses, (-) deformities or tenderness
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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
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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
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Cardiovascular
Inspection: (-) precordial bulge
Palpation: (-) heaves, (-) thrills, apex beat at
the 5th ICS left anterior axillary line
Auscultation: normal rate, regular rhythm
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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
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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
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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
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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
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Cranial Nerve XI ± good shoulder shrug
Cranial Nerve XII ± tongue is at the midline
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Motor: 5/5 in all extremities
Sensory: 100% sensation in all extremities
Cerebellar Exam
- (-) nystagmus, (-) dysmetria, (-)
dysdiadokinesia
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DIAGNOSTICS /LABORATORY
EXAMS
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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
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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
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DIAGNOSTICS
0
50
100
150
200
250
300
Day 3 Day 4 Day 5
Hemoglobin
Hematocrit
WBC
Platelet
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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
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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
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RUMPEL-LEEDE
C APILLARY FRAGILITY
TEST (TOURNIQUET TEST)
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DIAGNOSIS
Dengue, Non-Severe, with Warning Sign
Basis:
Living in an endemic area
Fever
Rash
Generalized weakness Positive tourniquet test
Decreasing platelet count
Lethargy
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DIFFERENTIAL DIAGNOSES
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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
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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.
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CASE D ISCUSSION:
EPIDEMIOLOGY AND TRANSMISSION
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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
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DENGUE CASE CLASSIFICATION
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1997 WHO CASE
CLASSIFICATION
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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)
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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
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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
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TRANSMISSION
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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.
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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
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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.
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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.
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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).
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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.
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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.
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CLINICAL MANAGEMENT AND
DELIVERY OF CLINICAL SERVICES
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THE COURSE OF DENGUE
ILLNESS
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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CLINICAL PROBLEMS IN THE
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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)
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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
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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
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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
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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).
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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.
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RECOMMENDATIONS FOR
TREATMENT
A STEPWISE APPROACH IN
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THE MANAGEMENT OF
DENGUE
Step 1 Overall assessment
Step 2
Diagnosis, assessment of disease phase and severity
Step 3 Management
STEP 1: OVERALL
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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,
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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
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HISTORY
Parameters Patient
Change in mental state NONE
Urine Output Patient claims to have nochanges in urination. (-)
anuria (-) dysuria
(-)dribbling
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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
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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
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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
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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).
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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
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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
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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
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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
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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
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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.
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MANAGEMENT IN THE
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M ANAGEMENT IN THE
ER
CBC with Platelet Count
Advised Admission
MANAGEMENT IN THE
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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
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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
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REFERENCE
WHO Dengue Guidelines for Diagnosis,
Treatement, Prevention and Control 2009