dengue hemorrhagic fever iii

8/8/2019 Dengue Hemorrhagic Fever III

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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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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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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

dengue hemorrhagic fever iii

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