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University of the East

Ramon Magsaysay Memorial Medical Center, Inc.


# 64 Barangay Doña Imelda, Aurora Boulevard Quezon City 1113

Name of Student: BATANES, Athena Marie A.


Section: 2020 A
Precept Group A4
PAPER CASE 3

1. DIFFERENTIAL DIAGNOSES of FEVER

Fever according to Nelson (2015), is defined as rectal temperature > 38C. When presented with fever
the following differential diagnoses may be considered give the other presentations of the patient:

Leptospirosis
Rule in: Clinical presentation is characteristic of leptospiroris and patient had a history of wading in the
flood.
Rule out: In the social history, patient did not have any open wound when he waded in the flood.
Bardychardia may also be associated with leptospirosis but this patient had tachycardia.

Malaria
Rule in: Malaria presents with fever, headache and vomiting as well.
Rule out: Although fever in malaria usually is more prominent in the afternoon.

Bronchopneumonia
Rule in: Fever of this long may be due to bronchopneumonia. Vomiting may be due to phlegm if there
was any.
Rule out: History shold include productive cough. Most often patient presents with rales and wheezes in
the lung especially in the basal area but patient’s chest/lungs findings had clear breath sounds.

URTI (bacterial)
Rule in: The presentations of the patient also seem to characterize upper respiratory tract infections.
Throat coule be irritated and may have cause the vomiting.
Rule out: Physical findings should present with hyperemic tonsils or erythematous pharynx.

UTI
Rule in: Acute fever and vomiting may also point to urinary tract infection.
Rule out: Pertinent PE finding of the patient should present with urinary sypmtoms. Since the patient is
just 8 years old it could be that he is just not complaining of urinary pain if any. Back pain could also be a
sign of UTI if any. Gold standard of pain is self-report and children might not be able to communicate
pain symptoms clearly.

Questions
1. Was there any rash present? If yes when did it appear throughout the course of the disease?
2. Was there any sign of bleeding?

2. PHYSICAL FINDINGS
Fever is a non-specific symptom that could mean infection, inflammation, neoplasm or less often
other miscellaneous category. The primary impression for this case given the patient’s clinical
manifestations is dengue, which is a viral infection that usually presents with fever. The associated signs
and symptoms of tachycardia and body malaise are often seen with fever, as is the case with this
patient. Retroorbital pain and headache are also common in dengue. Vomiting is also a notable dengue
presentation as well as epigastric pain. Presence of rash should also be asked in the history and
checked in physical examination. Hepatomegaly may also be a warning sign for dengue as well as any
sign of bleeding.

CASE DISCUSSION

Pertinent Subjective Data Pertinent Objective Data

 8 y/o  intermittent fever of 7 days (highest: 39.5C)


 Female, Filipino  T: 39C
 Jehovas witness  RR: 23/min
 (+) headache  HR: 110/min
 (+) retroorbital pain  BP: 90/60 mmHg
 (+) body malaise  O2 Sat: 98%
 (+) decreased appetite  (+) tenderness on epigastric
 (+) decreased activiyy  CRT: 2 seconds
 (+) epigastric pain  Dry lips
 (+) vomiting (1cup) every after eating  PARACETAMOL : 8.33mg/kg/dose (250mg/5ml
 (-) diarrhea for 30kg)
 Weight: 30kgs
 Height: 120cm
 BMI = 20.8

3. PRIMARY IMPRESSION: Dengue

The clinical presentation of patient points to a suspicion of dengue, especially if correlated with
complete blood count test results. For one, patient has had a 7-day intermittent fever. Epidemiologically,
dengiue is also endemic in the Philippines, a known tropical country. In this case, the patient also had an
exposure to another ill classmate in school which had dengue. This could mean that there could be
reservoirs of the etyiologic agent in the school. Frontal or retroorbital pain and myalgia are also seen in
patients with dengue.

The principal vector for Dengue is he Aedes egypti. Once bitten, incubation period of the virus
according to Nelson (2015) is around 1-7 days while others noted it averages at 3-5 days. The disease is
caused by 1 of the 4 strains. The virus is from the Flavivirus genus which attaches to the cell surface,
enters the cytoplasm and translates the viral protein leading to the different clinical manifestations.

Pertinent negatives help rule out concerns with the gastrointestinal tract. The absence of diarrhea
also helped in ruling out amoebiasis which could be a differential diagnosis. Appendicitis could have also

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been considered since patient had epigastric pain and anorexia accompanying the fever but pain for
appendicitis starts from the periumbilical region then shifts to the right lower quadrant. Moreover onset of
acute appendicits may not necessarily have a prolonged fever. The anti-pyretic medication given to the
patient was not enough and was an underdose. Dosage given is 6mg/kg/dose but recommended dose is
10-15mg/kg every four to six hours not exceeding five doses in 24 hours or 2.6 g per day. Patient should
be given at least 6-9ml.

Dengue can be classified by severity. This patient presented with Dengue with warning signs of
abdominal pain and tenderness and vomiting. CRT for stable circulation is brisk at <2 secs, prolonged
CRT at around >2 secs could mean compensated shock. This patient has 2secs as CRT and this should
me monitored especially since patient has dried lips upon physical exam as well.

DIAGNOSTICS AND ANCILLARY TESTS


This patient presents with an index of suspicion for duengue with warning signs. To confirm,
further tests may be provided:

 Complete blood count – to monitor platelet, WBC and differential count., hematocrit levels.
 Serum electrolytes determination – to check for loss due to vomiting
 Chest X-ray – to check for possible bronchopneumonia
 Urinalysis – Rule out UTI, but if patient denies any urinary symptoms this could be optional. This
could also help in detecting dehydration

4. MANAGEMENT AND PLAN

Dengue can be categorized according to the WHO into three: probable dengue, dengue with warning
signs and severe dengue. In this case, patient presents with dengue with warning signs. Patient should
be referred to in-hospital management where strict observation and medical intervention should be
facilitated. Complete blood count is important to help assess the platelet count. Platelet count in dengue
decreases and as this happens hematocrit level may rise. This could be a sign of plasma leakage if
present. Therefore, acquisition of CBC and HGT levels before beginning fluid therapy is essential.

Parient should be given only isotonic solution (0.9% NaCl) or Ringer’s Lactate with or without glucose
depending on the HGT levels. To start with, patient should be given around 150ml/hour for the first 1-2
hours. Guide for rate of infusion is:

 First 1-2 hours: 5-7ml/kg/hour


 Next 2-4 hours: 3-5ml/kg/hour
 Depending on clinical response reduce to 2-3ml/kg/hr.

Patient’s CBC and HCT levels should be continuously monitored to assess response to therepy. If
HCT remains the same or minimally increases the rate should be maintained for another 2-4 hours.
Should there be any worsening, however, rate of infusion may be increased to 5-10ml/kg/hour for 1-2
hours.

Since patient is a jehovas witness, patient’s choice should be considered and ethically should be
respected should she refuse blood transfusion as per religious belief. Therefore, patient should be
hydrated well.

References:

Nelson’s Texbook of Pediatrics 20th edition. (2015).


Manual on Pediatrics