Dengue Hemorrhagic Fever III

By: Katrina Tugado and Jehrisse Soriano

Identifying data:
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
Source and Reliability
Parents, both with 85% reliability
Chief complaint:
Fever of six days duration
History of Present Illness
6 days PTA,
The patient had intermittent undocumented
moderate grade fever, the patient was given
Paracetamol syrup 250 mg/5 ml, 10 ml every four
hours (29 mkdose)
Accompanied by epigastric pain not relieved by
food intake
There were also five episodes of vomiting of
previously ingested food amounting to 2
tablespoons/episode
There were no cough, colds, abdominal
distention, diarrhea noted and no consult was done
History of Present Illness
5 days PTA,
There was persistence of undocumented moderate
grade fever
Epigastric pain decreased in frequency
Vomiting was also noted to decrease, 3 episodes were
noted, composed of previously ingested food
amounting to 2 tbsps./ episode
Paracetamol syrup 250 mg/5 ml, 10 ml every four
hours (29 mkdose) was continued
No changes in activity and appetite noted, no consult
was done
History of Present Illness
3 days PTA,
Intermittent undocumented moderate grade fever
persisted
Epigastric pain and vomiting with the same
characteristics as before persisted.
No cough, colds, bleeding and melena were
noted
Consult at Bermudez Polymedic Hospital was
done and the patient was admitted for 1 ½ days
CBC; PC was done which revealed:
History of Present Illness
7/23 (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
Platelets 320 314 256 220
History of Present Illness

Urinalysis and serum electrolytes were done

but results were unrecalled
Impression was dengue fever and the patient
was advised transfer to a tertiary hospital for
further evaluation and management.
History of Present IIlness
1 day PTA,
The patient was transferred to Tala Hospital,
impression given was also Dengue fever.
CBC was done but with unrecalled results.
He was also given unrecalled medications for
abdominal pain and was advised transfer to a
tertiary hospital hence transfer to NCH
Past Health Maintenance History
(-) PTB
(-) pneumonia
(-) asthma
(-) chicken pox
(-) measles
Gestational History
The mother had no known feto-maternal complications
No intake of medications/ x-ray exposure
Regular PNCUs at 4 months until birth
With regular intake of multivitamins and ferrous
sulfate
Birth History
The patient was born full term via normal spontaneous
delivery at a lying-in clinic to a 26 year old G2P2
(2002) mother.
Neonatal history
(+) spontaneous respiration
(-) jaundice
(-) convulsions
(+) weight gain
Feeding History
Breastfed from 0-2 mos.
Formula fed from 2 mos-1 year old (Nestogen (1:1))
Started on solids at 7 mos.
Previously with good appetite
Multivitamins started at birth until present (Tiki-tiki,
Ceelin)
Present diet: rice, fried chicken, pork
(-) vomiting
(-) food intolerance
Developmental History
Roll over at 6 mos.
Sat alone at 6 mos.
Stood alone at 12 mos.
Walk alone at 15 mos.
Talked at 2 y.o.
Immunization History
1 dose of BCG
3 doses of DPT
3 doses of OPV
3 doses of Hep B
1 dose of measles
Family History
Mother, 32 y/o apparently healthy
Father, 37 y/o apparently healthy
8 y/o male sibling, with dengue fever
(-) PTB
(-) DM
(-) Asthma
(-) Congenital defects
(-) Mental retardation
Physical examination
General survey: awake,afebrile, coherent, not in
cardiorespiratory distress
Vital signs: BP: 80/50 mmHg, CR: 118 bpm, RR: 30,
T: 36.6 C
Anthropometrics: Wt: 17 kgs. Ht: 103 cm
HEENT: Anictric sclerae, pink palpebral sclerae, no
tonsillopharyngeal congestion, no
cervicolymphadenopathies
Thorax and Lungs: Equal chest expansion, decreased
breath sounds at the lower lung fields
CVS: adynamic precordium, normal rate and rhythm,
no murmurs
Abdomen: flat, soft, tenderness on the epigastric area
and right flank, NABS
Extremities: poor pulses, CRT > 4 secs, cold
extremities
Rectal exam: no skin tags, no fissure, with good
sphincter tone, empty rectal vault with yellowish
material upon withdrawal of the examining finger
Abdomen: flat, soft, tenderness on the epigastric area
and right flank, NABS
Extremities: poor pulses, CRT > 4 secs, cold
extremities
Subjective data:
Moderate grade undocumented fever
Epigastric pain
Vomiting
A sibling with the same symptoms
Objective data:
Low Hgb
Low Hct
Decreasing platelet count (NV: 150-450 x 10 9 L)
Tenderness of the epigastric are upon palpation
Poor pulses, CRT > 4 secs, cold extremities
DHF vs. DF
Dengue 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)
Defervescence: 3-8 days usually
followed by minor hemorrhagic
phenomena, others may progress to
severe GI bleeding and shock
Dengue Hemorrhagic fever
Same with DF in the early phase of
illness
Usually with high fever, hemorrhagic
phenomena, hepatomegaly, circulatory
failure
Defervescence: 2-5 days
Simultaneous or sequential introduction
of two or more serotypes,
Presents with thrombocytopenia (<100,
000) and hemoconcentration
Dengue Hemorrhagic fever
Hepatic enlargement and tenderness is a sign of bad
prognosis.
Other manifestations include pleural effusion and
hypoalbuminemia, encephalopathy with normal
cerebrospinal fluid.
Diffuse capillary leakage of plasma is responsible for
the hemoconcentration
Thrombocytpenia + hemoconcentration
Prognosis:
The case-fatality of DHF/DSS is 10% or higher if
untreated.
With supportive treatment, fewer than 1% of such
cases succumb.
Recovery is rapid and without sequelae
WHO classification:
Grade I - thrombocytopenia + hemoconcentration.
Absence of spontaneous bleeding.
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).
Differentials:
Leptospirosis:
Ruled in:
Fever, abdominal pain, vomiting of six days duration
Malaria
Ruled in:
 Daily fever presentation
Ruled out:
 Spleen enlargement
 Jaundice