On examination, patient is alert and conscious. Pulse: rate is 110, weak and volume is poor. Capillary refilling time: more than two seconds Peripheral examination: cold periphery BP: 90/40 Temperature: 38 degree celcius, Lung, Cardiovascular and Abdominal examination is unremarkable. FBC was taken and the result are shown below: WBC:2.9 Hb:14 HCT:42 Plt:60

Questions 1) Describe your finding in the picture 2) What is your complete provisional

diagnosis? 3) How do you diagnose dengue fever? 4) Describe grading of dengue fever 5) Explain regarding phases of dengue

fever 6) How do you manage this patient 7) What is the complication of dengue

fever

9 years old girl with High Grade Fever and Rash 9 years old girl presented with complaint of fever for 5 days duration. There are no symptoms of URTI, UTI, AGE, ear discharge, altered mental status and fitting.

Image Courtesy of Dr Dr Muna Athirah, Duchess of Kent Hospital

Answer 1) Petichae with characteristic of “Islands

of white in a sea of red” ** Usually during recovery phase..

2) Dengue Hemorrhagic fever in critical phase with compensated shock ** Physician must able to identify provisional diagnosis of dengue, phase of illness, hydration and haemodynamic status (shock or not) and whether require admission

? Critical phase: Temperature starts to normalize, 3rd to 7th day of illness, thrombocytopenia, hemoconcentration, leucopenia ? Compensated shock: Clear consciousness, capillary refilling >2s, cool extremities, weak and thready peripheral pulse, tachycardia

3) Antibody detection (Dengue Serology

Test like Haemagglutination Inhibition Test, Dengue IgM test, Indirect IgG ELISA test, Dengue Rapid tests), virus isolation, detection of virus genetic materials (polymerase chain reaction -PCR) and detection of dengue virus protein (NS1 antigen).

4) WHO Classification for Dengue Fever

a) Dengue fever b) Dengue Hemorrhagic fever mild (grade I and II) Dengue shock syndromes (grade III and IV)

5) Complication - Acute abdomen - Hepatitis and liver failure - Encephalitis or encephalopathy - Hypovolumic shock, DIC

6) Grading of dengue fever

7) Management for this patient - Admit patient to the wards - Insert two large bore IV line, CBD - fluid resuscitation 10-20 ml/ kg

crystalloid blus - QID FBC to monitor HCT and

platelet - Put patient on IV maintanence - Repeat the bolus if no

improvement. May repeat up to 3 bolus (third one with colloids)

- 15-30 minutes vital sign monitoring until stable, and then 1-2 hourly

- twice a day monitoring for warning sign, general well being (appetite/oral intake), bleeding symptoms, neurological/ mental state

- Hourly urine output monitoring - Daily BUSE/Creat, LFT, RBS,

Coagulation profile, Acid base imbalance

- Admit patient to Intensive care unit if condition worsen. Consider blood product transfusion, inotropes.

- Dengue notification form (24H)