A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever...
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Transcript of A Case of N.E. 16 y.o Male cc: fever x 3 days. History of Present Illness 3 days PTC: (+) fever...
A Case of N.E.16 y.o Male
cc: fever x 3 days
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
(-) epistaxis(-) gum & aural bleeding(-) hematemesis(-) hematuria(-) hematochezia(-) melena(-) petechiae/ ecchymoses/ rash
Px has a neighbor diagnosed with Dengue
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
• (-) calf pain• (-) abdominal pains• (-) jaundice• (+) good urine output• (-) hx of wading through
the floodwaters
History of Present Illness
3 days PTC: (+) fever with chills
(Tmax 39.5ºC)(+) headache (+) generalized
weakness(+) myalgia (+) sore throat(+) cough with
productive sputum (whitish)
Medications taken:
Paracetamol 500mg/tab every 4 hours for fever with minimal relief
Review of Systems
(-) dizziness(-) difficulty of breathing(-) chest pains(-) palpitations(-) weight loss >20%(-) decrease in appetite
Past Medical History
(-) hypertension, diabetes, liver, lung and kidney disease
(-) asthma, allergies to food and drugs (-) previous hospitalizations and surgeries
Birth and Maternal History
Pt was born FT at Fabella hospital by an OB-Gyne via SVD to a then G1P0 mother.
(-) maternal illness, exposure to chemicals, radiation
(-) exposure to measles and varicella infection
Immunization History
completed the EPI c/o LHC(+) MMR c/o private pediatrician
Nutritional History
Px was fed with both breastmilk and formula since birth.
The patient’s current diet consists of rice, meat, fish, poultry, with minimal fruits and vegetables
Personal and Social History
H - good rel’p with parents & siblingsE - 2nd year HS, satisfactory performance, (-)
failing gradesA - basketball, computer gamesD - no use of illicit drugsS - has groups of friends in school and
neighborhoodS - not sexually activeS - no suicidal thoughts
Personal and Social History
Non-smoker, occasional alcoholic beverage intake
Px lives with his mother and 2 other siblings at home in Pasay City
Mother is the breadwinner of the family and works in a factory
Px’s family gets monthly stipend from relatives who work abroad
GenogramHPNAsthma
CVDPTB
32 30 27 24 16
7 9
Physical ExaminationBP 90/60 HR 120s RR 20 T 38.6Px is awake, coherent, oriented, weak-lookingPinkish conjunctivae, anicteric sclerae, (+) pharyngeal
injection, (-) cervical lymphadenopathies, (-) anterior neck masses, (-) nasoaural bleeding, (-) gum bleeidng
Equal chest expansion, clear breath sounds, (-) wheezes, (-) crackles, (-) retractions
Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs
Soft and flat abdomen, normoactive bowel sounds, (-) masses/ tenderness, liver and spleen nonpalpable
Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-) clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses, (-) calf tenderness, (+) flushed skin
Tourniquet Test
negative (<20 spots in 1 square inch)
Assessment
R/O Dengue Fever/ Dengue Hemorrhagic Fever
Plan
For CBC with platelet countParacetamol 500mg/tab 1 tab every 4
hours for feverTepid sponge bathSupportive therapy
Increase oral fluid intakeAvoid dark colored foodsWOF bleeding episodes
Questions Questions…..
What if the CBC was normal? It has only been a 3 day Hx of fever..
A negative tourniquet test doesn’t necessarily r/o DF/DHF.. What now?
Its too early to say.. What can we do at this point? Is watchful waiting enough to prevent the complications of DF/DHF?
Recent dengue cases are noted to be more virulent than the past (cross-immunities etc)
DF/DHF Epidemiology
10,383 cases of DF/DHF noted by Nat’l Epidemiological Center of DOH (Jan-June 20)
104 deaths (case fatality of 1%)Most cases were at NCR, Region 4A, 5,6Most deaths are caused by complications
secondary to DHF and DSSMost are diagnosed LATE
Bio-Rad Dengue NS1 Antigen Test
New offer at PGH Central Lab!!Used in private hospitals since 2007 serum available in minutesMay detect 4 dengue serotypes in the
first 5 days of viremia (febrile phase)
Diagnostic Dilemma
P - pediatric patients with clinical signs of Dengue Fever, in the first 3 days of fever
I - Dengue NS1Antigen testC - virus isolation testO - sensitivity and specificity in diagnosis
of Dengue FeverM - cross sectional study
Clinical Question (Diagnostics)
What is the sensitivity and specificity of Dengue NS1Antigen test versus a viral isolation test in the diagnosis of DF/DHF in pediatric patients with clinical signs of DF in the first 3 days of viremia in a cross sectional study?
Therapeutic Dilemma
P - Pediatric patients with clinical signs of systemic viral infection (SVI)
I - ImmunologicalsC - placeboO - shortening the course of the diseaseM - RCTs
Clinical Question (Therapeutics)
In pediatric patients with clinical signs of systemic viral infection, is there a significant difference in giving immunologicals versus placebo in shortening the course of fever seen in randomized controlled trials?