DENGUE FEVER

Date of Interview
Time of Interview
Source of Data
: Mar 2, 2018
: 03:55 PM
: Grandmother
M.R.B.
8-year old, Female
Reliability : 95% Roman Catholic, Filipino,
Referral : Private clinic Brgy. Baso, Cabucgayan, Biliran

FEVER
 HISTORY OF PRESENT ILLNESS
The patient was apparently until four days prior to admission, she
had undocumented on and off moderate grade fever not associated with
headache, cough & colds, nausea & vomiting, loss of appetite,
abdominal pain, diarrhea or constipation. She was immediately brought
to Naval Rural Health Center where in after assessment she was given
Paracetamol 125 mg/5 ml at 10 mg/kg/day rendering temporarily relief
of fever. She was sent home with instruction to continue Paracetamol
every for 4 fours for fever.
 HISTORY OF PRESENT ILLNESS

Three days prior to admission, still with episodes of undocumented

intermittent fever, body weakness, loss of appetite now associated with
occasional mild abdominal pain and 2 episodes of non-projectile
vomiting of scanty clear vomitus. She was continuously given with the
prescribed Paracetamol 125 mg/5 ml at 10 mg/kg/day every four hours
for fever rendering relief temporarily however fever eventually recur
hours after.
 HISTORY OF PRESENT ILLNESS

Seven hours prior to admission, with the persistence of the above

symptoms they sought consult in a private clinic. Complete blood count
and urinalysis were requested with unrecalled results. The doctor
considered dengue fever and urinary tract infection. There was no
medication given. She was advised admission and referred to our
hospital, hence admission.
REVIEW OF SYSTEMS
General: No weight loss, (+) loss of appetite, (+) body malaise, (+) fever

SKIN : brown complexion, no rashes, no itching, and no discoloration

HEENT
Head : (+)headache, (+) dizziness, (+) history of head injury
Eyes : no redness, no pain, no excessive tearing, no blurring of vision
Ears : no hearing loss, no vertigo, no earache, no discharge, no tinnitus
Nose and sinuses: no colds, no itching, no epistaxis, no nasal stuffiness, no
nasal congestion
Mouth and throat: no bleeding gums, no sore tongue, no sore throat, no
dry mouth, no hoarseness of voice, no dysphagia
REVIEW OF SYSTEMS
Neck : no swollen glands, no stiffness, no pain
Breast: no pain, no discharges, no lumps and masses

Respiratory : no cough, no dyspnea, no hemoptysis, no orthopnea

Cardiovascular : no chest discomfort, no palpitation, no orthopnea,
no paroxysmal nocturnal dyspnea
Gastrointestinal : (+) abdominal pain, (+) vomiting, bowel movement
once a day with brown semi formed stool, non-bloody,
no pain in defecation, no nausea, no hematemesis, no
heartburn, no excessive belching.
REVIEW OF SYSTEMS

Urinary : no dysuria, no dribbling, no burning pain, no hematuria, no

polyuria, no nocturia, usually urinates 4-6 times approximately
200 ml per urination of yellow colored urine.

Genital : no sores, no itching, no discharges

Peripheral vascular : no intermittent claudication, no varicosities,

no leg cramps, no stiffness
REVIEW OF SYSTEMS
Musculoskeletal : no backache, no joint pains
Neurologic : no changes in orientation, no changes in memory,
insight, or judgment, no seizure, no motor and sensory
loss, no tremors
Hematologic : no bleeding gums, no easy bruising
Endocrine : no excessive sweating, thirst and hunger, no heat and
cold intolerance, no polyuria
Psychiatric : no history of depression, no nervousness, no mood
swings, no history of suicide attempts, no memory
change
24 Hour Diet Recall

Breakfast : 2 sliced bread 100 calories

½ glass of chocolate drink 46 calories
1 glass water

Snacks : 1 pack sky flakes 120 calories

1 glass water

Lunch : ½ cup of rice 100 calories

3 matchbox size serving of chicken 129 calories
1 glass water

Snacks : 1 piece of bread 50 calories

1 cup milk 46 calories

Dinner : ½ cup of rice 100 calories

2 matchbox size serving of fish 86 calories
1 glass water

TOTAL CALORIC INTAKE PER DAY: 777 calories

 GROWTH AND DEVELOPMENT
GROSS MOTOR AVE.AGE OF ATTAINMENT AGE ATTAINED (in months)

Pulls to sit, with no head lag 3 3

Sits with support 6 6
Rolls over 6.5 7
Walks alone 12 11
Runs 16 15

FINE MOTOR

Reaches for objects 4 4

Transfers object from hand to hand 5.5 6
Scribbles 13 12
Drinks from cup 15 15
Feeds well with spoon 24 24
 GROWTH AND DEVELOPMENT
COGNITIVE AVE.AGE OF ATTAINMENT AGE ATTAINED (in months)

Stares at 2 hands 4 4

Uncovers toys 8 8

Bangs 2 objects 8 8

Pretend play 17 16

LANGUAGE

Social smile 2 2
Monosyllabic babble 6 6
Mama or Dada 10 10
Speaks 4-6 words 15 15
Knows full name 24.5 24
Names one or more colors 24 24
 PAST MEDICAL HITORY

Immunization : Fully immunized as claimed by the grandmother

Illnesses : Measles & mumps (didn’t have chicken pox, dengue fever)
: No previous confinement

Surgical : No minor or major surgical operations

Psychiatric : None

No known allergy to food or any drugs

 FAMILY HEALTH HISTORY
The patient’s father is a 28-year old, college graduate,
unemployed. Her mother is a 28-year old, college graduate
working as a call center agent. Both of them are apparently
well.

The patient’s grandmother (maternal) claimed to have

hypertension and diabetes mellitus.
 PERSONAL SOCIAL HISTORY
The patient is an 8 years old, female, residing with her
grandparents in a concrete bungalow typed well ventilated house
located along the national high way. Their source of drinking water is
commercially purchased and water for general use is from water
pump. Their toilet is manually flushed water sealed located inside
their house. Their garbage is collected regularly every day. They use
gas stove to cook meals and boil water. Food is stored into a clean
plastic container with cover. They observe hand washing every after
toilet use and maintain cleanliness in food preparation. There is visible
stagnant water near them and mosquitos can be seen. They do not
have dogs or cats. Her father who is separated from them does not
smokes cigarette but drink alcoholic beverages occasionally. Her
mother doesn’t smoke and drink. Their total income monthly ranges
 PERSONAL SOCIAL HISTORY
Patient MRB is a grade 3 pupil in Cabucgayan Elementary
School. She belongs to top performing students in their class.
Her favorite subject is science. She has many friends at
school and neighbors and actively play with them whenever
school time is over or during weekends.

The patient has no history of recent travel to other

places. The patient’s grandmother confirmed that there are
cases of dengue fever in their neighborhood.
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
General Survey

Patient was examined lying in bed, conscious, coherent, conversant,

weak looking, well groomed, mesomorph, not in cardio-respiratory distress,
febrile, well developed with the following vital signs and anthropometric
measurements:

Weight : 26 kg. (Ideal: 27 kg.)

Blood Pressure : 100/70 (Ideal: 90-110/70-80)
Temperature : 37.8 C (Ideal: 36.5-37.5 C)
Heart Rate : 92 bpm (Ideal: 60-100 bpm)
Respiratory Rate : 26 cpm (Ideal: 16-20 bpm)
 PHYSICAL EXAMINATION
Actual Ideal Z-score
Weight 26 kg 27 kg 0
Height 126 cm 130 cm 0
Mean Arm Circumference 16 cm ---- ----
Body Mass Index (BMI) 16.35 16.00 0

WATERLOW CLASSIFICATION OF WATERLOW CLASSIFICATION OF

WASTING STUNTING

Actual Weight/ Ideal Weight for age x100 Actual Length/ Ideal Length for Age x 100

26 kg/ 27 kg x 100 126/130 x 100

96 % (NO WASTING) 97 % (NO STUNTING)

 PHYSICAL EXAMINATION
Integument
Skin : brown complexion, warm, moist, no lesions, no petechiae, no
ecchymoses with good skin turgor, no edema
Nails : pink nail beds, without clubbing or cyanosis, CRT <2 seconds

Head
Skull : normocephalic, with long, black fine hair equally distributed,
temples not depressed, no nits and lies, no scalp lesion, no
dandruff, no engorged veins, no flakes, and no tenderness
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Eyes:
Eyebrow : symmetrical with equally distributed hair
Eyelashes : short, fine, curved, black oriented outwards
Eyelids : no ptosis, lid lag, discharges, tenderness, swelling, nodules,
Eyeballs : globes firm on pressure, full EOM
Conjunctiva: pinkish palpebral conjunctiva, no discharges, no lesions,
no ulcers or spots
Sclera : anicteric, without hemorrhages
Cornea : clear, no ulceration, no scars
Pupils : 2-3 mm in diameter and briskly reactive to direct
and consensual light, with good accommodation and good
convergence
 PHYSICAL
PHYSICAL EXAMINATION
EXAMINATION
Ears: symmetrical, auricle in line with the outer canthus of the eye, dry cerumen noted on ear
canals, no impacted cerumen, no discharges, no hearing loss, no tenderness, no lesions

Nose and Sinuses: pink mucous membrane, septum at midline, no discharges, no congestion,
no nasal flaring, no nasal polyps, non-perforated nasal septum, no sinus tenderness

Mouth : Pink mucous membrane, no sores, no ulcerations

Lips : Symmetrical, pinkish color, no lesions, no cheilosis, no angular deviation
Gums : Pinkish, no bleeding
Teeth : With complete set of teeth, no dentures
Tongue: Pinkish, midline upon protrusion, no ulceration

Throat:
Uvula at midline, tonsils not enlarged, no lesions, no discharges
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Neck
Inspection : No neck vein engorgement, neck moves without
discernible restriction, no lesions, trachea at midline,
no lumps
Palpation : Neck supple, thyroid not enlarged and moves with
deglutition, no palpable lymph nodes

Breast
Inspection : Symmetrical, brown areola and nipples at the same level,
no lesions, no discharges
Palpation : No lumps, no palpable lymph nodes, no tenderness
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Chest and Lungs
Inspection:
Symmetrical lung expansion, no lagging, no subscapular and
intercostal retraction on respiration, breathing not labored
Palpation:
Bilateral symmetrical lung expansion, unimpaired tactile fremitus, no
masses, no tenderness
Percussion:
Resonant all over lung fields.
Auscultation:
Bronchovesicular breath sounds over all lung fields, no crackles, no
rales, no wheezing, no pleural friction rub
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Cardiovascular
Inspection
No precordial bulging, no visible pulsation

Palpation
PMI noted at 5th ICS mid clavicular line, no heaves, no thrills, no lumps,
and no tenderness

Auscultation
Heartbeat is 92 bpm with normal rate & regular rhythm, synchronous
with radial pulse 92, no murmur, S1 louder than S2 at apex, S2 louder
than S1 at base, no pericardial friction rub
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Abdomen
Inspection
Full, symmetrical, no visible pulsation and peristalsis, no distended veins,
no scars, no bulging flanks.
Auscultation
Normoactive bowel sounds, no bruits, no peritoneal friction rubs,
Percussion
Tympanitic in all regions, liver span 6 cm at right MCL and 5cm at
midsternal line, Splenic span of 5 cm at anterior axillary line,
Palpation
Soft, nontender, liver, spleen and kidneys not palpated, no ballotable
organs, bladder not palpable, no mass, no lumps, negative kidney
punch
PHYSICAL
PHYSICAL
EXAMINATION
EXAMINATION
Back and Spine:
Inspection : no abnormal deviation, no retraction, no bulging, no mass, no
scars
Palpation : no paravertebral tenderness or mass, negative kidney punch
test

Extremities
Inspection : equal in length and size, full range of motion, no rashes, no
cyanosis, no varicosities, no edema
Palpation : skin is warm and moist, all pulses 2+ equal and symmetric no
muscle tenderness
NEUROLOGIC EXAMINATION
Mental Status
Conscious, coherent, responsive, conversant, oriented to time, place and
person
Language and Speech
No aphasia nor dysarthria
Cerebellar
No involuntary movements, no ataxia
Cranial Nerves
No cranial nerve deficits
Motor Function
Flex and extend upper and lower extremities without limitation, no atrophy
of muscle, no involuntary movements, no spasticity, no rigidity, no flaccidity,
muscle strength grade 5.
NEUROLOGIC EXAMINATION
Reflexes
Biceps 2+ Triceps 2+
Brachioradialis 2+ Patellar 2+
Plantar 2+
Pathologic Reflexes
(-) Babinski
(-) Ankle clonus
Meningeal Signs
(-) Brudzinki's sign
(-) kernig sign
(-) nuchal rigidity
Autonomic Nervous System
(-) incontinence, excessive sweating lacrimation, salivation
 COURSE IN THE WARD

LABORATORIES AND X-RAYS

MARCH 2, 2018 (Admission)
TIME SUBJECTIVE & OBJECTIVE LABORATORIES DIET AND MEDICATION SUPPORTIVE
03:45 PM Fever for 3 days CBC, Platelet, blood typing Diet for age except dark colored Strict I&O monitoring then record
Headache Urinalysis foods
Mild abdominal pain Dengue Rapid Test Monitor vital signs every 4 hours
Vomiting Venoclysis PLR 1 liter let 200 cc fast then record
Loss of appetite drip then regulate remaining at 25
Body weakness gtts/min Watch out for bleeding signs,
narrowed pulse pressure &
Vital signs: Medications: hypotension
BP: 90/60 mmHg Cefuroxime 750 mg IVTT every 8
HR: 92 bpm hours
RR: 26 cpm Paracetamol 250 mg/5 ml, 7 ml every
T: 37.8 C 4 hours for fever
O2 Sat: 99%
09:20 PM BP: 90/60 Increase IVF to 35 gtts/min
HR: 90 bpm IVF to follow PLR 1 liter at 35 gtts/min
Full pulses
10:30 PM Repeat CBC, platelet count
now
Follow up and relay result
STAT
11:40 PM Serial hematocrit & platelet Strict I&O monitoring then record
count every 6 hours to start
at 6 PM Monitor vital signs every 4 hours
then record
MARCH 3, 2018 (Day 1)
TIME SUBJECTIVE & OBJECTIVE LABORATORIES DIET AND MEDICATION SUPPORTIVE
05:00 AM Good sleep, fair appetite, STAT hematocrit platelet Decrease IVF to 30 gtts/min
conscious, coherent, oriented count defer 6 AM collection,
& conversant refer Omeprazole 25 mg thru IVTT now
Vital signs: then OD
BP: 90/60 mmHg
HR: 114 bpm
RR: 21 cpm
T: 36.4 C
O2 Sat: 99%
(+) RUQ tenderness on light
palpation
With full pulses
06:45 AM BP: 90/60 Hematocrit and platelet count Insert another IV line for Voluven 500 Strict I&O monitoring then record
Full pulses monitoring every 4 hours cc let 150 cc run as fast drip and
Inadequate urine output start at 9 AM regulate the remaining at 20 gtts/min Monitor vital signs every 4 hours
Soft abdomen, nontender Regulate PLR 1L at 20 gtts/min then record
Clear breath sounds Pedialyte 30 at least 2 bottles a day

09:30 AM (+) history of trauma For skull x-ray APL, relay

(+) headache result
12:00 PM Decrease present IVF to 15 gtts/min For Dengue closed watch
(2cc/kg/hr)
06:45 PM Reduce serial hematocrit and Reduce Voluven 500 cc at 15 gtts/min
platelet count to every 6 Reduce PLR 1L at 15 gtts/min
hours start at 11 PM Follow up PLR 1L at 15 gtts/min
MARCH 4, 2018 (Day 2)
TIME SUBJECTIVE & OBJECTIVE LABORATORIES DIET AND MEDICATION SUPPORTIVE
12:30 AM BP: 90/60 mmHg Follow Voluven 500 cc at 15 gtts/min
Full pulses Continue PLR 1L at 15 gtts/min
UO: 2.1cc/kg/hrx16H

08:15 AM 48 hours afebrile Reduce Voluven to 10 gtts/min Strict I&O monitoring then record
Awake, conscious
Bloated abdomen Continue PLR 1L at 15 gtts/min Monitor vital signs every 4 hours
Full pulses then record
UO: 2 cc/kg/24 hours

08:20 AM Weak looking Maintain Voluven at 10 gtts/min then Continue BP, HR, RR every 4 hours
Full pulses consume and shift to heplock line monitoring
(+) ascites
Slightly decreased breath Increase PLR 1L to 25 gtts/min once
sounds Voluven is consumed

BP: 90/70 mmHg Give IVTT meds then heplock once

HR: 103 bpm voluven is consumed
RR: 23 cpm
Follow up PLR 1L at 20 gtts/min
MARCH 5, 2018 (Day 3)

TIME SUBJECTIVE & OBJECTIVE LABORATORIES DIET AND MEDICATION SUPPORTIVE

08:45 AM (+) Herman’s rash Reduce serial hematocrit and Furosemide 20 mg slow IVTT now
(+) Ascites platelet count to every 8 Reduce IVF rate at 15 gtts/min
hours Cetirizine (alnix) 7,5 ml now then OD
Chest X-ray Result
(03/06/2018)

BIBASAL PNEUMONIA
BILATERAL PLEURAL FLUID
Hematocrit & Platelet Count
Monitoring

3/5/18 5 AM 0.35 106

1 PM 0.33 112
9 PM 0.35 134

3/6/18 8 AM 0.33 148

 SALIENT FEAUTURES
8 Years Old/Female

F E V E R
4 Days Intermittent Fever

Body Weakness, Loss Of Appetite, Mild Abdominal Pain,

Non-Projectile Vomiting
Dengue cases in neighborhood
Stagnant waters near the house with visible mosquitos
Weak Looking, Temperature: 37.8 C, Skin warm to touch
No rashes, no retroorbital pain, no epistaxis, no bleeding gums
APPROACH TO DIAGNOSIS
Fever

Rheumatologic/ Malignancy/
Miscellaneous
Infectious Inflammatory Neoplastic
Disorders
disorders disorders

Juvenile
Drug-Induced
Viral Rheumathoid
Fever
arthritis

Rheumatic
Bacterial
Fever

Others
Reference: Jin Han Kang. Febrile illness with skin
rashes. Infect Chemother. 2015 Sep; 47(3): 155–
166.
 APPROACH TO DIAGNOSIS
CHIKUNGUNYA LEPTOSPIROSIS URINARY TRACT INFECTION
Intermittent fever Intermittent fever Intermittent fever
(-) Conjunctival
Body weakness, loss Bodysuffusion
weakness, loss Body weakness, loss of
of appetite, mild (-)appetite,
of Photophobia
mild appetite, mild
abdominal pain, abdominal pain, non- (-) Dysuria
abdominal pain, non-
non-projectile
(-) Diarrhea
projectile vomiting projectile vomiting
(-) Arthralgia
vomiting (-) Muscle pain (-) Abdominal
(-) Calf pain tenderness
Stagnant waters
near the house with
(-) History of contact
visible mosquitos to contaminated
water
APPROACH TO DIAGNOSIS
DENGUE FEVER

Intermittent fever

Body weakness, loss of appetite, mild

abdominal pain, non-projectile vomiting
CANNOT TOTALLY
Stagnant waters near the house with
RULE OUT
visible mosquitos

Dengue cases in neighborhood

 IMPRESSION

DENGUE FEVER
WITH WARNING SIGNS
DISCUSSION
 • Benign syndrome caused by several arthropod-
borne viruses (Flavivirus: Arbovirus)
• Composed of single-stranded RNA; Four serotypes
(Dengue 1,2,3,4)
• Transmitted by mosquitoes of the Stegomyia family

MOSQUITO
• Aedes aegypti
- daytime biting mosquito,
- principal vector
- all 4 virus types have been recovered from it.
- in most tropical areas, it is highly urbanized, breeding in water stored for
drinking or bathing and in rainwater collected in any container.
• Aedes albopictus
- 2001 Hawaiian epidemic
- breed in water trapped in vegetation.
 390 million dengue infections
occur annually
 96 million have clinical
disease.
 Dengue outbreaks in urban
areas infested with A. aegypti
may be explosive; up to 70-
80% of the population may be
involved.
 Most overt disease occurs in
older children and adults.
Legend- Cases
1.00- 500.00
500.01-1000.00
1000.01-1500.00
1500.01+
• Living or travelling to an
endemic area (mostly
tropical places)

• Standing water outdoors

and indoors such as artificial
containers, vases cleansed
at least once a week.
Variable and are influenced by the age of
the patient.

INFANTS AND YOUNG

CHILDREN
The disease may be undifferentiated
or characterized by:
• Fever for 1-5 days
• Pharyngeal inflammation
• Rhinitis and mild cough
OLDER CHILDREN AND ADULT
• Sudden onset of fever • The pulse rate may be slow relative
(39.4-41.1°C) to the degree of fever
• Frontal or retroorbital pain • Myalgia and arthralgia occur soon
• Severe backpain precedes the fever after the onset of fevers and
(back-break fever) increase in severity over time.
• Transient, macular, generalized rash • Joint symptoms
that blanches under pressure may be
seen during the 1st 24-48 hr of fever.
2nd-6th day of fever
• Nausea and vomiting,
• Generalized lymphadenopathy
• Cutaneous hyperesthesia or hyperalgesia
• Taste aberrations
• Pronounced anorexia
 CLINICAL
 Abdominal pain/tenderness
 Persistent vomiting
 Clinical fluid accumulation
 Mucosal bleed
 Lethargy
 Restlessness
 Liver enlargement >2 cm
WARNING! LABORATORY
 Increase in hematocrit with rapid
decrease in platelet count
MANAGEMENT
PATIENTS WHO MAY BE SENT HOME
MANAGEMENT
DENGUE WITH WARNING SIGNS (HOSPITAL)
MANAGEMENT
DENGUE WITH WARNING SIGNS (HOSPITAL)
 MANAGEMENT
DENGUE WITHOUT WARNING SIGNS (HOSPITAL)
MANAGEMENT
DENGUE WITH COMPENSATED SHOCK
… you will see me struggle,

but you will never see me quit..