Department of Family & Community MedicinePerpetual Succour Hospital

BLEEDING LOVEFAMILY CASE PRESENTATION

1st Year ResidentCrisbert I. Cualteros, M.D.

Postgraduate InternsAlaba, Clevan Teresita

Encong, AubreyTaghoy, Josie Mae

Tancongco, ZiphoraTingcang, Marvic Mae

Nisnisan, Arvin

Objectives:

General Objective:To present a case of Dengue Hemorrhagic Fever

Specific Objectives:1)To discuss the family profile of Curaraton-

Tundag Family 2)To present the index case with Dengue

Hemorrhagic Fever3)To discuss briefly DHF4)To establish the family diagnosis, intervention and recommendation using family assessment tools

Family Profile

THE HOUSE

• 16 x 19 feet house• 1 bedroom• With CR inside

bedroom

LIVING AREA

DINING AREA AND KITCHENDINING AREA KITCHEN AREA

FAMILY LIFE LINE

1988: “Basta Driver – Sweet Lover!”•Ruben worked as a family driver at a well-

known subdivision in Cebu City where Magdalena was a nanny. Magdalena was the one who brought the employer’s daughter to school and it was Ruben who drove them. Friendship bloomed between the two. Magdalena was always excited by these moments, as well as Ruben. This continued for a year.

May 1989: “CARELESS WHISPER” •Ruben and Magdalena developed deeper

feelings for each other so they decided to live together. For 7 months, they stayed in a rented house near their workplace.

•Ruben transferred and got another job, still as a family driver. Magdalena supported Ruben’s decision.

1990: “When 2 Become 1”•Ruben and Magdalena’s relationship

became more intimate and finally, Ruben asked Magdalena’s hand in marriage.

•Opportunity came and Magdalena resigned from being a nanny and transferred to MEPZA (in a tailoring company) and worked there for 6months.

1991: “Confused??? Pag-sure oi!”•After her contract expired, Magdalena

transferred to Mandaue to work at a food factory (Cheese Curls) as a production worker.

•Due to economic reasons, Magdalena transferred again to a number of other companies in search of greener pastures. (Accessories maker for 3 years, room attendant for 4 years at a pension house)

Sept 2002: “Oh Baby, Baby”•Because of their undying love, Mary Eve

was born after twelve years of their living together.

Oct 2004: “Baby One More Time”•Not too long after, their second child was

born and they named him Robert John.

Economic Profile

Total Monthly Income

8,000 – 8,500 PERCENT ALLOCATIO

N

Total Monthly Expenses:

Food: Electricity: Water: Medicine: Miscellaneous:

8,2004,500 – 5,000700400800-9001,300

96.5%53%8.3%4.7%10.5%16%

Savings 300 3.5%

Curaraton-Tundag Family

• Nuclear Family• Externally Patriarchal• Internally Matriarchal• 4 members

Magdalena • 40 years old• Mother• Housewife• Non-smoker• Non-alcoholic

beverage drinker• 1993- Cardiomegaly• Unrecalled meds

taken for a month

Ruben• 45 years old• Father• Shipper/ delivery man• Occ’l alcoholic

beverage drinker• Smoker for >20years,

3 sticks/day• 1990-Psoriasis, took

MX3 capsule TID, Clobetasol propionate (Dermovate) + Petroleum jelly BID, Unrecalled anti-allergy PRN

Mary Eve•7 years old•Grade 1 pupil•Colegio Del Santo Nino•Non-asthmatic•No illness

Robert John •4 years old•Male child•Index patient•Nursery pupil•No medical problem

Prenatal, Natal& Postnatal History:•Fullterm•NSD at a Lying-in Clinic•Birth Rank: 2/2•No birth complications•Breastfed up to 3 months then mixed fed•Weaned at 5 months•Complete primary immunization at BHC

Past Medical History

•No medical problem•No allergies•Previous Hospitalization: none•HFD: HPN, DM & BA

History of Present Illness:

•2 days PTA, fever noted (38 oC), was given Paracetamol with temporary relief. No consult done. Condition was tolerated.

•Night PTA, above condition was associated with nausea and vomiting, consult with AP, was given Metoclopramide and Cefadroxil.

History of Present Illness:

•CBC was taken which showed thrombocytopenia.

•Persistence of above condition associated with vomiting of brownish-colored vomitus and abdominal pain prompted admission.

Physical Examination

•Gen Survey: Patient was irritable, afebrile, not in respiratory distress with the ff v/s:

BP:90/60 HR:139 RR:34T:37.4*C Wt : 15 kgs

•Skin: flushed, warm with good turgor

Physical Examination•HEENT: Pink palpebral conjunctivae,

anicteric sclerae, no epistaxis, dry lips and tongue with minimal gum bleeding

•Neck: supple, no LAD

•C/L: equal chest expansion, harsh breath sounds, no rales, no wheeze

•CVS: adynamic precordium, distinct heart sounds, no murmur

Physical Examination

•Abd: flat, normoactive bowel sounds, soft, with mild epigastric area tenderness

•GUT: negative KPS bilaterally

•Ext: warm, CRT<2 secs, strong peripheral pulses

•CNS: WNL

DENGUE HEMORRHAGIC FEVER STAGE 1, GRADE 2

IMPRESSION

On admission:

•IVF started, 300 cc was given as MFD(20cc/kg), then regulated to 70 cc/hr (4.6cc/kg)

•Additional Labs: u/a, Na, K, BT B(+), Creatinine

•Meds: ▫Paracetamol 250/5, 5mL q4hrs PRN▫Famotidine 15mg IV q12hrs

1st Hospital Day4TH Day of Illness•S – fever, no epistaxis, no gum bleeding,

no vomiting•O - BP: 100/60 HR:86 RR:24 T:39.6

U/O: 3.7cc/kg/hrSkin: flushed, warm with good turgorHEENT: no epistaxis, dry lips Abd: mild epigastric area tendernessExt: warm, strong pulses, CRT<2 sec

•A – DHF Stage 1, Grade 2•P – to continue CBC monitoring

▫To monitor for any sign of bleeding▫Identify 1 standby donor for possible plt

apheresis▫IVF increased to 5cc/kg (80 cc/hr)▫Continue meds

5/24/09 12mn 5/24/09 6AM

WBC 1.88 1.34

HGB 11.3 11.7

HCT 34.4 35.9

PLT 115 80

DAY 4 OF ILLNESS

2nd Hospital DayDay 5 of illness•S – fever, (-)BM for 3days, no bleeding, •O - BP: 80/50 90/60 HR:120 RR:25

T:38.6 U/O: 5cc/kg/hrSkin: cold clammy skin HEENT: Pink palpebral conjunctivae, anicteric sclerae, no epistaxis, dry lips, moist tongue

•Abd: flat, normoactive bowel sounds, soft, with mild epigastric tenderness

• Ext: cold, strong pulses, CRT 2-3 sec•A – DHF Stage 1, Grade 3•P – to continue CBC monitoring

▫Identify 1 standby donor for possible plt apheresis

▫Continue Paracetamol PRN and Famotidine, Fibrosine 1 sachet

▫Cefuroxime 500 mg IV q8 (AD:100)

5/25/09

1am

5/25/09

6AM

WBC 1.06 1.05

Hct 33.3 29.7

Plt 65,000 75,000

DAY 5 of ILLNESS

3rd – 4th Hospital DayDay 6 Illness•S – fever, (+)BM, no bleeding•O - BP: 90/60mmHg HR:100-104 bpm

RR:25-26 cpm T:38.2-39.2 oC U/O: 5cc/kg/hr

Skin: (+) Herman’s rash, warm with good turgorAbd: flat, normoactive bowel sounds, soft, with mild epigastric & RUQ tenderness

•A – DHF Stage 1, Grade 3•P – to continue CBC monitoring

▫Identify 1 standby donor for possible plt apheresis

▫Cefuroxime 500 mg IV q8 (AD:100)▫Continue Paracetamol PRN and Famotidine▫Cetirizine PO

3rd and 4th Hospital DayDays 6 and 7 of Illness

5/26/09 5/27/09

12mn 5am 12nn 7pm 6am 12nn 8pm

WBC 1.54 1.53 1.66 1.87 2.62 2.72 3.57

Hct 32.8 32.4 32.6 35 34.7 30.8 34.3

Plt 85 60 50 60 85 50 70

5th Hospital DayDay 8 of Illness, Day 1 afebrile

•S – afebrile, no bleeding, with improving appetite

•O - BP:90/60 HR:115 RR:26 T:37.6 U/O: 5.2cc/kg/hr

Skin: (+) Herman’s rash, warm with good turgorAbd: flat, normoactive bowel sounds, soft, no tendernessExt: warm, strong pulses, CRT<2 sec

•A – DHF Stage 2(afebrile), Grade 2•P – to continue CBC monitoring

- IVF decreased to 50cc/hr (3.3cc/kg)▫Cefuroxime 500 mg IV q8 (AD:100)▫Continue Paracetamol PRN and Famotidine▫Cetirizine

5/28/09

5am 4pm

WBC 3.81 5.33

Hct 34.2 34

Plt 65 60

5th Hospital DayDay 8 of Illness, Day 1 afebrile

6th Hospital DayDay 9 of Illness, Day 2 afebrile•S - Afebrile, with improving appetite, not

irritable•O - BP:90/60 HR:100 RR:26 T:36.5

U/O: 5cc/kg/hrSkin: (+) Herman’s rash, warm with good turgorHEENT: red inflamed Lips & strawberry tongue, tonsils not enlarged

•A – DHF Stage 3(convalescent), Grade 3 - R/O Kawasaki Disease

•P – referred to Pedia for comanagement - IVF decreased to 30cc/hr (2cc/kg)▫Cefuroxime was shifted to

Imepenem+Cilostazol▫Continue Paracetamol PRN and Famotidine▫Cetirizine▫CRP negative▫ESR: 39 (N:0-10)

5am 10am

WBC 9.35 7.08

Hct 32.5 29.9

Plt 140 140

6th Hospital DayDay 9 of Illness, Day 2 afebrile

7th Hospital DayDay 10 of Illness, Day 3 afebrile

•S - Afebrile, with improving appetite, not irritable

•O - BP:90/60 HR:104 RR:26 T:37.2 U/O: 5cc/kg/hrSkin: (+) Herman’s rash, warm with good turgorHEENT: Pink palpebral conjunctivae, anicteric sclerae, no epistaxis, reddish lips & tongue, tonsils not enlarged

•C/L: equal chest expansion, clear breath sounds

•CVS: distinct heartsounds, no murmur•Abd: flat, normoactive bowel sounds, soft,

no tenderness•Ext: warm, strong pulses, CRT<2 sec

•A – DHF Stage 3(convalescent), Grade 3

•P - MGH

Graphical Summary of Temperature

FINAL DIAGNOSIS:

•Dengue Hemorrhagic Fever - Grade 3

Dengue Hemorrhagic Fever

Introduction:

•Dengue virus•Is an arbovirus •Transmitted by mosquito (Aedes aegypti)•Composed of single-stranded RNA •Has 4 serotypes (DEN-1, 2, 3, 4)

•Each serotype provides specific lifetime immunity vs. the same serotype

•All serotypes can cause severe and fatal disease

•Some genetic variants within each serotype appear to be more virulent or have greater epidemic potential

Transmission of Dengue virus by Aedes aegypti

Replication and Transmission of Dengue Virus

 1. Virus transmitted to human in mosquito saliva2. Virus replicates in target organs3. Virus infects wbc and lymphatic tissues4. Virus released and circulates in blood 5. Second mosquito ingests virus with blood6. Virus replicates in mosquito midgut and other organs, infects salivary glands 7. Virus replicates in salivary glands   

Aedes aegypti• female mosquito• Identified by the white

bands or scale patterns on its legs and thorax

• Primarily a daytime feeder

• Lives around human habitation

• Lays eggs and produces larvae preferentially in artificial containers

Vector Control Methods

•involves eliminating/controlling the larval habitats where the mosquito lays eggs and the immature mosquitoes develop

•Includes emptying water from containers or covering containers that are being used, clean up campaigns to dispose of containers that are not being used

Dengue Fever•acute febrile illness of 2-7 days duration

with 2 or more of the ff:•headache•retro -orbital pain•myalgia/arthralgia•rash•petechiae and positive tourniquet test• leukopenia.

WHO criteria for DHF:

•Fever, or recent history of acute fever

•Hemorrhagic manifestations •Low platelet count (100,000/mm3 or less)

•Objective evidence of plasma leakage

Objective evidence of plasma leakage:

>Elevated hematocrit (20% over baseline, or 20% drop after volume replacement)>Low protein>Pleural effusion/ ascites

•Plasma leakage is the critical difference between DHF and DF

Dengue Shock Syndrome •4 criteria for DHF •Evidence of circulatory failure manifested

by: ▫Rapid and weak pulse ▫Narrow pulse pressure/ hypotension ▫Cold, clammy skin and altered mental

status •Frank shock is direct evidence of

circulatory failure

Warning Signs for Dengue Shock                          

Disease Course•Febrile phase lasting 2 -7 days•Critical phase which is about 2-3 days

after febrile stage>the patient is afebrile>is at risk of developing DHF/DSS•Convalescent phase – recovery phase>7-10 days after critical stage>Further improvement in general condition

and return of appetite>Confluent petechial rash with white

center/ itching

Positive Tourniquet Test

                                                                                                                                              

(+)Torniquet Test: more than 20 petechiae/ sq inch.

Treatment of Dengue Fever •Rest•Fluids. Patients should be encouraged to

take small, frequent sips of fluids. If the patient cannot be rehydrated by mouth, fluids should be administered intravenously. At times large amounts of intravenous fluids are needed

•Antipyretics—aspirin and NSAIDS such as ibuprofen should be avoided.

•Monitoring of BP, urine output, HCT, PLT, and level of consciousness.

Volume Replacement Flow Chart for Patients withDHF Grades I and II

Indications for Hospital Discharge•Absence of fever for 24 hours & return of

appetite •Visible improvement in clinical picture •Stable hematocrit •3 days after recovery from shock •Platelets >50,000/mm³ •No respiratory distress from pleural

effusions/ascites Source: Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever:

Guidelines for Prevention and Control. PAHO: Washington, D.C., 1994: 69.

Family Assessment Tools

FAMILY CIRCLE

Magdalena

Curaraton – Tundag Genogram

FAMILY IN FUNCTIONAL EQUILIBRIUM

Robert John recovered from his illnessRuben was able to go back to workMagdalena can now attend to Mary eve’s needs

STRESSFUL EVENT: When Robert John was confined at PSH due to fever and was diagnosed to have DHF

ADAPTATION•Ruben was able to get a cash advance from his employer•Some of the consultants did not charge them•They were able to borrow money from Ruben’s siblings

RESOURCES•Financial support from Ruben’s siblings.•Neighbors were also helping them by watching over Robert John in the hospital and taking care of Mary eve

FAMILY IN DISEQUILIBRIUM

• Ruben misses work• Ruben’s salary deducted •Magdalena couldn’t attend to Mary eve’s needs.

RESOLVE: I am satisfied with the way my family and I share time together

AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love

GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions

PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me.

ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me.

Hardly Ever (0)

Some of the Time (1)

Almost always(2)

FAMILY APGAR

Magdalena Curaraton: Mother

APGAR SCORE 7: MODERATELY DYSFUNCTIONAL FAMILY

SCREEM Resource

Social adequate Robert John’s family participates in social activities such as family reunions, fiesta celebrations of their relatives residing in the provinces. They also have good relationships with their neighbors, friends and co-workers.

Cultural adequate They have embraced Filipino values and apply these in their everyday life (i.e. showing respect by kissing the hands of elderly).

Religious adequate The family attends mass every Sunday in Capitol Parish and Basilica del Santo Nino. They are aware of religious events in the local community.

Economic inadequate Ruben is working as shipper/delivery man of marine products for export and Magdalena is a housewife. Their monthly income is sometimes not enough to provide the basic necessities of the family.

Educational adequate Ruben and Magdalena are highschool graduates hence, making them capable of solving problems rationally.

Medical adequate When medical problems arise, the family can easily access their private physician to seek consultation for proper medications.

RECOMMENDATIONS

To the parents:• Should be educated regarding the proper

prevention of dengue.• Should be educated on the signs and symptoms

of dengue.• They should have a regular check up of the

patient’s well-being and immunizations.

RECOMMENDATIONSMagdalena - mother

• Should be educated regarding the proper prevention of dengue.

• Make sure that her children get adequate nutrition to increase resistance from any diseases.

Ruben – father• Should be compliant of his maintenance

medications for psoriasis to prevent flares and avoid missing work.

• Should also be educated as well regarding the proper prevention of dengue.

RECOMMENDATIONS

To the resident-in charge:• Follow-up with Robert John’s progress and

Ruben’s maintenance medications.• Make sure that the family maintains the

cleanliness of the surroundings to prevent sources of infection.

• To educate the parents of Robert John and their neighbors about the importance of cleanliness in the environment.

RECOMMENDATIONSTo the family as a whole if there is

suspicion of another possible dengue infection:• Rest, drink plenty of fluids and consult a

physician • Avoid pain relievers that contain aspirin and

NSAID such as ibuprofen. Paracetamol may be used.

• To eliminate mosquito breeding sites and reduce the risk of dengue by checking around their house and to empty buckets, cans, flower pots and other items that may contain water.

• Use insect repellents and spray insecticides if there are mosquitoes in the vicinity.

RECOMMENDATIONS

▫To eliminate any containers where mosquito can lay egg by covering them/turning them upside down

▫By installing window and door screens

FAMILY DIAGNOSIS• Curaraton-Tundag Family

• Nuclear type• Middle class• Father – breadwinner• Mother – primary caregiver

• The stage of family cycle: Family with Young Children

• APGAR Assessment: Moderately Dysfunctional Family (Score 7)

• Smilkstein’s Family Cycle: family is in equilibrium.• Evaluation by SCREEM showed resource and

strength of Social, Cultural, Religion, Education, and Medical factors and weakness and pathology in economic factor.