Lapjag Bangsal IPD 22 OKTOBER DHF

8/10/2019 Lapjag Bangsal IPD 22 OKTOBER DHF

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G P O N D U T Y : D R . T I K AR E S I D E N T O N D U T Y : D R . E V I R O S S A

C O - A S S O N D U T Y :

L E O N Y N E R R Y S . T A M B U N A N

R A D E N A N N I S A C I T R A P E R M A D I

DUTY REPORT WARD UNIT

22NDOCTOBER , 2014


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PATIENTSRECAP

3rdfloor

Nasopharingeal Carcinoma

4thfloor POST SYNCOPE

IBD

Anemia, with susp. Pneumonia

SIDA

6thfloor

DHF


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PATIENTS IDENTITY

Name : Mr. J

DOB : 17 Feb 1989

Age : 25 y.o

Gender : Male

Occupation : Unemployed

Address : Manggarai Jakbar

Medical Record no. : 225164

Date of admission : 22nd October , 2014 at 01.00WIB


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ANAMNESIS

Chief Complain: Fever since 4 days before admission

History of present illness:

Patient came with fever since 4 days before admission. FEVER

all day

Relieved by paracetamol on day 2 but not to the baselinetemperature

No fever prior to admission (day 4)

Associated with diarrhea, 7 times a day on the 4thday > thestool is watery, no blood, no mucus, no pus, no waste, not oilynor smelly with yellow brownish color.

Nausea and Vomiting (+), 3 times a day, food containing vomit

Autoanamnesa at 01.00 WIB on 22ndOctober 2014


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Patient denied

any bleeding from gum, nose, bloody stool or urine

Headache

Pain in the back of the eyes

Rash

Abdominal pain

Muscle ache

This is the first time patient experiences thesecomplaints.


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History of past illness: Denies any history of hypertension, DM, heart problems, stroke,

asthma, hepatitis, and allergies.

Family History: No known family member or relatives have the same

complaints

History of Socio-habits: Smoking 1 pack/day since 3yr before admission No history of drinking alcohol No one in the relatives or family or collegue have the same

complaints

History of medications: Paracetamol 3 x 500 mg for 3 days


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PHYSICIAL EXAMINATION

GENERAL EXAMINATION

General condition :

Consciousness : compos mentis

Blood pressure : 120/80 mmHg HR : 88x/min, regular, full

RR : 18x/min, thoracoabdomino, kussmaul (-)

Body temperature : 34 C

Body Weight : 96 kg

Body Height : 170 cm

IMT : 33,2 (obese)


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PHYSICAL EXAMINATION

Head: normocephal

Hair: normal distribution, black color

Face: symmetrical, deformity (-)

Eye: pale conjunctiva -/-, icteric conjunctiva -/-, -

ENT: normotia, normosepta, rhinorrhea (-), otorrhea (-), blood(-),hyperemic pharynx (-), calm T1-T1

Mouth: mucous is normal

Neck: Lymphadenopathy (-)

Skin: warm, pale (-)


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Thorax

Pulmonary Examination

Inspection : normochest, symmetrical chest movement on staticand dynamic. ICS retraction (-), no rash

Palpation : symmetrical chest expansion and tactile fremitus, (-)mass, (-) tenderness

Percussion : sonor at both lung field

Auscultation : bronchovesicular +/+, rhonchi -/-, wheezing -/-


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Thorax

Cardiac Examination

Inspection : invisible ictus cordis

Palpation : impalpable ictus cordis

Percussion

Right heart border : Right parasternal line

Left heart border : Left midclavicular line

Heart waist : ICS III left parasternal line

Auscultation : S1/S2 regular, gallop (-), murmur (-)


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Abdominal examination

Inspection : not distended, mass(-)

Auscultation : normal bowel sound ; 8x/min

Palpation : tenderness and rebound tenderness alll overregio (-),hepatomegaly and splenomegaly (-)

Percussion : timpani

Special examination : shifting dullness (-), fluid wave (-)

Rumple Leed : +

Extremities: warm skin, pale (-) CRT


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RUMPLE LEED


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RUMPLE LEED


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RESUME

Male, 25 y.o, came with fever since 4 daysbefore admission, with no rash, anybleeding from gum, nose, bloody stool or

urine, headache , retroorbital pain, rash,abdominal pain, myalgia, shortness ofbreath. On physical examination, vital signsare normal, percussion on both lung fields

are sonor, there is no sign of peuralefussioin nor asictes and the positiverumple leed test. On the work up lab,patient has hemoconcentration andtrombocytopenia.


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LIST OF PROBLEMS

1. Acute Fever

2. Nausea and vomiting

3. Diarrhea

4. Obese

5. Hemoconcentration

6. Thrombocytopenia


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DIAGNOSIS

Working diagnosis

Dengue Hemorrhagic Fever gr I


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DENGUE HEMORRHAGIC FEVER

Complete 4 of the following criteria :

Fever or history of fever lasting 27 days, occasionally biphasic

A haemorrhagic tendency shown by at least one of thefollowing: a positive tourniquet test*; petechiae, ecchymoses

or purpura; bleeding from the mucosa, gastro-intestinal tract,injection sites or other locations; haematemesis or melaena

Thrombocytopenia [(100,000 cells/mm3 (1006109/L)]{

Evidence of plasma leakage due to increased vascularpermeability shown by: an increase in the haematocrit >20%above average for age, sex and population; a decrease in

the haematocrit after intervention >20% of baseline; signs ofplasma leakage such as pleural effusion, ascites orhypoproteinaemia


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PLANNING

DIAGNOSTIC PLAN MANAGEMENT PLAN

CBC Non Pharmacology :- Bed rest- Soft Dietary- Urine catheter placement

Serology Test (IgM, IgG) Pharmacology :- Fluid Therapy RL

NS-1 Antigen - Ondancentron 3 x 4 mg IV

SGOT/SGPT - Paracetamol 3 x 500 mg PO

Radiology > X-ray Thorax AP,Lateral Decubitus


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FLUID REPLACEMENT

LOADING DOSE

5-7 ml/kg/hr 1-2 hr500 cc in 1-2hr

3-5 ml/kg/hr in 2-4 hr300 cc in 2-4hr

2-3 ml/kg/hr or less according toclinical response

200 cc/hr

Monitor VS (4 hourlyurine output(4-6hrly)Hct(before & after fluidreplacement then 6-12hrly)

BG

MAINTANANCE

1500 + 20 (BB-20)

1500 + 20 (96-20)3020 ml/24 hr


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PROGNOSIS

Quo ad Vitam: bonam

Quo ad functionam: bonam

Quo ad sanactionam: bonam


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REFERENCES

DENGUE


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EPIDEMIOLOGY

Most important arthropod-borne viral diseases interms of human morbidity and mortality.

Important public health problem.

Tropical & subtropical regions around the worldurban and semi urban areas


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VIROLOGY

Dengue virus

mosquito-borne flavivirus.

Transmitted by

Aedes aegypti Aedes albopictus.

DEN-1, 2, 3 and 4.


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VIROLOGY

Each episode of infection

a life-long protective immunity to the homologous serotype

partial & transient protection against subsequent infectionby the other three serotypes.

Secondary infection is a DHF major risk factor


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VIROLOGY

Other important contributing factors for DHF are

viral virulence

host genetic background

T-cell activation

viral load

auto-antibodies


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SPECTRUM OF INFECTION

The incubation period is 4-7 days (range 3-14)

Asymptomatica spectrum of illness

Undifferentiated mild febrile illnesssevere disease

(plasma leakage (-/+_) & organ impairment Systemic & dynamic disease with

Clinical

Haematological

Serological profiles changing from day to day.


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PATHOPHYSIOLOGY

Increased vascular permeability is the primarypathophysiological abnormality in DHF/ DSS.

Increased vascular permeability leads to plasma

leakage and results in hypovolaemia/ shock.


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PATHOPHYSIOLOGY

The pathogenetic mechanism for the increased

vascular permeability (?)

Destructive vascular lesions (-)

post-mortem (microscopically), perivascular oedema

loss of integrity of endothelial junctions endothelial dysfunction

AbN immune response

production of cytokines or chemokines,

activation of T-lymphocytes disturbances of haemostatic system

C3a, C5a, TNF-, IL-2, 6 & 10, IFN-, histamine


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TOURNIQUET TEST

In DHF grade 1(+) tourniquet test serves as theonly indicator of haemorrhagic tendency.

Sensitivity0% to 57% (phase of illness)

5-21%false positive

How to perform tourniquet test

Inflate the blood pressure cuff on the upper arm toa point midway between the systolic and diastolic

pressures for 5 minutes.

A positive test is when 20 or more petechiae per2.5 cm (1 inch) square are observed.

The 1997 WHO classification of dengue virus infection


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The 1997 WHO classification of dengue virus infection.


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DFProbable

An acute febrile illness with two or more of thefollowing manifestations: headache, retro-orbitalpain, myalgia, arthralgia, rash, haemorrhagicmanifestations and leucopenia

And

Supportive serology (a reciprocalhaemagglutination-inhibition antibody titre >1280, acomparable IgG enzyme-linked immunosorbentassay (ELISA, see chapter 455) titre or a positive IgM

antibody test on a late acute or convalescent-phaseserum specimen)

Or

Occurrence at the same location and time as otherDF cases


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Confirmed A case confirmed by one of the following laboratory

criteria: Isolation of the dengue virus from serum/autopsy samples At least a four-fold change in reciprocal IgG/IgM titres to one

or more dengue virus antigens in paired samples Demonstration of dengue virus antigen in autopsy tissue, serum

or cerebrospinal fluid samples by immunohistochemistry,immunofluorescence or ELISA

Detection of dengue virus genomic sequences in autopsytissue serum or cerebrospinal fluid samples by polymerase

chain reaction (PCR)Reportable Any probable or confirmed case should be reported


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DHFFor a diagnosis of DHF, a case must meet all four of the

following criteria: Fever or history of fever lasting 27 days, occasionally

biphasic A haemorrhagic tendency shown by at least one of the

following: a positive tourniquet test*; petechiae,ecchymoses or purpura; bleeding from the mucosa,gastro-intestinal tract, injection sites or other locations;haematemesis or melaena

Thrombocytopenia [(100,000 cells/mm3 (1006109/L)]{ Evidence of plasma leakage due to increased vascular

permeability shown by: an increase in the haematocrit>20% above average for age, sex and population; adecrease in the haematocrit after intervention >20% ofbaseline; signs of plasma leakage such as pleuraleffusion, ascites or hypoproteinaemia


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DSS

For a case of DSS, all four criteria for DHF must bemet, in addition to evidence of circulatory failuremanifested by:

Rapid and weak pulse

And Narrow pulse pressure (,20 mmHg or 2.7 kPa)

or manifested by

Hypotension for age

And Cold, clammy skin and restlessness


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World Health Organization. DengueGuidelines for Diagnosis, Treatment,Prevention and ControlNew Edition 2009. WHO: Geneva; 2009


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The following manifestations are important indengue infection but are often under- recognisedor misdiagnosed

Acute abdomen :

Hepatitis and liver failure :

Neurological manifestation :

Haemophagocytic syndrome


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DISEASE MONITORING LABORATORY

TESTS

Full Blood Count (FBC)

1. White cell count (WCC) :

2. Haematocrit (HCT) :

3. Thrombocytopaenia :

Liver Function Test


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DIAGNOSTIC TESTS

DENGUE SEROLOGY TESTS

Haemagglutination Inhibition Test

Dengue IgM test

Indirect IgG ELISA test Cross-react with:

other flavivirusJapanese Encephalitis

non-flavivirusmalaria, leptospirosis, toxoplasmosis, syphilis

connective tissue diseasesrheumatoid arthritis

VIRUS ISOLATION POLYMERASE CHAIN REACTION (PCR)

NON-STRUCTURAL PROTEIN-1 (NS1 Antigen)


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Clinical and Laboratory Criteria for Patients Who Can be Treated atHome


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The following should be taken into considerationbefore discharging a patient.

Afebrile for 48 hours

Improved general condition

Improved appetite

Stable haematocrit

Rising platelet count

No dyspnoea or respiratory distress from pleural effusionor ascites

Resolved bleeding episodes

Resolution/recovery of organ dysfunction


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THANK YOU

Lapjag Bangsal IPD 22 OKTOBER DHF

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