DENGUE FEVER

AEDES AEGYPTI
JO QUEENSTEIN LYDIA L. ROBEL
JUNIOR INTERN
 OBJECTIVES

THIS PRESENTATION AIMS TO:

• To recognize the clinical presentation of a pediatric
patient with dengue fever;
• To determine the classification of dengue fever presented;
• To determine what diagnostic tests to perform for dengue fever;
• To initiate appropriate management of dengue fever.
 IDENTIFYING DATA

• A.K.T, 12/F
• June 04, 2006
• Roman Catholic
• Filipino
• V & G Tacloban City
• Admitted for the time at RTRH on Feb 04, 2019 at 10A.M.
Chief complaint:

fever & vomiting

 History of present illness

4 days prior to admission

• fever (Tmax: 39 C)
• no other associated signs and symptoms
• Paracetamol 500mg/tab 1 tab q 4 hours
• temporary relief
 History of present illness

1 day prior to admission

• afebrile
• Hypogastric pain
• no other associated signs and symptoms
• Sought consult, labs (CBC, UA) requested
• Increased hematocrit, WBC 2.5, Platelet 312
• pyuria
• Cefuroxime 500mg BID x 7 days
 History of present illness

5 hours prior to admission

• febrile
• Diffuse abdominal pain
• headache
• 3x nonprojectile, nonbilious vomiting
 PAST MEDICAL HISTORY

Measles and Chickenpox

X mumps

asthma (last attack 7 y/o)

Allergic rhinitis
X allergies to food and drugs
 PAST MEDICAL HISTORY (cont.)

2017 RTRH  Pneumonia and UTI

2015 RTRH  Dengue

 FAMILY HISTORY
QUINTERO-TANA FAMILY
Feb 04,, 2019
? ? ? V&G Tac City ?

I
xx
Evarnesto
x
Pilar
x
x
Sixto
x ?
Charito
69 50 77 79
I I I I I I I I
-- --
II

Aly Kristine

LEGEND:
Hypertension -
DM -

III
Kamille 10
27 12
 PSYCHOSOCIAL HISTORY

H has close /harmonious relations with family

members

E Grade VI at LVD , top 1 in class

E Eats almost anything, no special preferences

A likes to sing and dance

 PSYCHOSOCIAL HISTORY

D no history of illicit drug use

S likes female companions and gets attracted to the

opposite sex

S no suicidal thoughts

S Tanner sexual maturity rating stage II

 RISK FACTORS

• Family lives near a creek, a possible breeding

ground for mosquitoes
• Lives in V & G Tac City
 PHYSICAL EXAMINATION
GENERAL SURVEY
• Awake, conscious, cooperative, not in cardiorespiratory distress
• Mesomorph and well-groomed
• Febrile
VITAL SIGNS ACTUAL VALUE
Blood Pressure 100/60 mmHg

Temperature 38.9 °C (L axilla)

Heart Rate 89 bpm

Respiratory Rate 22 cpm

Weight 38.6 kg

Height 151 cm
 PHYSICAL EXAMINATION (cont.)

INTEGUMENT
• Fair complexion, warm, good skin turgor
• Nails pinkish, normal CRT
• No masses, no lumps, no rashes
HEAD
• Hair black, short, fine, average in texture
• No nits/lice infestation, no visible flakes
• No lumps, no tenderness, no scars, no engorged veins
 PHYSICAL EXAMINATION (cont.)

EYES
• Eyebrows symmetrically aligned, fine, black
• Eyelashes fine, black, oriented outwards
• Eyelids not edematous
• Pinkish palpebral/bulbar conjunctiva
• Non-sunken eyeballs
EARS
• Symmetrical, firm pinnae
• No abnormal discharge and no active lesions
 PHYSICAL EXAMINATION (cont.)

NOSE
• (-) Septal deviation, (-) Epistaxis, (-) Nasal flaring
MOUTH & THROAT
• Dry lips
• Mucous membrane/gums pinkish
• No bleeding/sores
NECK
• Supple, trachea at midline, neck veins not engorged
• No lymphadenopathies
 PHYSICAL EXAMINATION (cont.)

CHEST AND LUNGS

• Symmetrical chest expansion, no bulging
• No supraclavicular, intercostal, and subcostal retractions
• Resonant in all lung fields
• Clear breath sounds, no crackles and wheezes
HEART
• Adynamic precordium
• Apex beat palpable at 4th ICS LMCL, (-) thrills/heaves
• HR at 89 bpm, regular in rhythm
• (-) Murmurs
 PHYSICAL EXAMINATION (cont.)

BACK AND SPINE

• (-) Abnormal deviation, (-) retractions
• (-) Bulging, (-) muscle wasting
GENITOURINARY
• Not performed
RECTUM/ANUS
• Not performed
 nEUROLOGIC EXAMINATION
MENTAL STATUS EXAM: The patient is conscious, active, oriented to time, place, and
person, and attentive.
CRANIAL NERVES:
• CN I – It was elicited by letting the patient recognize the smell of perfume
• CN II – Pupils are 2 mm in diameter, equally round and reactive to direct and
consensual light stimulation and accomodation
• CN III, IV, and VI –EOM were intact and was elicited by letting the patient look at a
pen which moves in all directions while his head is steady
• CN V – Patient is able to sense pain and touch
• CN VII – Patient is able to smile and frown
• CN VIII – Responsive to verbal stimuli
• CN IX and X – Able to swallow solid food and liquids with ease
• CN XI – Able to turn head to both sides against resistance; able to shrug
• CN XII – Able to protrude tongue without any deviation
 neurologic EXAMINATION (cont.)

MOTOR
• Grade 5
• (-) limitation of movement, (-) atrophy, spasticity/rigidity of
muscles
SENSORY
• No sensory deficits
REFLEXES
• All 2 +
CEREBELLUM
• No ataxia
 IMPRESSION
IMPRESSION: DENGUE FEVER WITH
T/C DENGUESIGNS
WARNING FEVER

BASIS:
• HISTORY OF PRESENT ILLNESS:
• Patient had onset of fever with Tmax of 39 C
• Had vomiting episodes
• PHYSICAL EXAMINATION:
• Patient is febrile T= 38.9 C
• RISK FACTOR
• Family lives near a creek (may be a breeding ground for
mosquitoes)
• Lives in V & G Tac City
 DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
INFLUENZA CHIKUNGUNYA
Rule In: Rule In:
• Fever • Fever
• Tropical areas (Philippines) • headache
• headache Rule Out:
Rule Out: • Myalgia
• Myalgia • Arthralgia
• Malaise, cough • Joint pains
• Sore throat • Rash
• Diarrhea • No hemorrhagic manifestations
• No hemorrhagic manifestations
CLINICAL PRACTICE
GUIDELINES
Myalgia
 REVISED DENGUE CASE CLASSIFICATION (WHO 2009,
DOH 2011)
Dengue without warning signs Dengue with warning signs Severe Dengue

1. Probable dengue 1. Clinical warning signs Manifestation of dengue with or without

- Lives in or travels to dengue endemic area
- Fever plus 2 of the ff:
a. Nausea and Vomiting
b. Rash
c. Aches and Pains
d. Tourniquet test
- Laboratory tests: leukopenia
Dengue NS1 Antigen Test or
IgM antibody test
1. Laboratory-confirmed dengue
- Viral culture isolation
- PCR
- Lives in or travels to dengue endemic area warning signs plus any off the following:
- Fever for 2-7 days plus any of the ff: 1. Severe plasma leakage, leading to:
a. Abdominal pain or tenderness a. Shock (dengue shock syndrome)
b. Persistent vomiting b. Fluid accumulation with respiratory
c. Clinical fluid accumulation distress
d. Mucosal bleed 1. Severe bleeding
+/- e. Lethargy, restlessness 2. Severe organ involvement:
Dengue f. Liver enlargement > 2cm a. Liver: AST or ALT >1000
1. Laboratory warning signs b. CNS: Impaired consciousness,
- Increase in Hct seizures
- Rapid decrease in Platelet count c. Cardiac: Impaired function (e.g.,
myocarditis)
d. Renal: impaired function (e.g.,
azotemia)

- Requires strict observation and medical intervention. Warning signs mark the beginning of the critical phase
- Important when there are no signs of plasma leakage
- Evidence of plasma leakage: high or rising hematocrit, pleural effusion or ascites, signs of shock
Clinical Presentation of Dengue Infections
Tourniquet Test
 Management in the Febrile Phase
1. Reduction of fever
- Recommend only paracetamol
- If fever is not reduced, tepid sponge with warm water is
recommended
- Increase in fluid intake also helps reduce body temperature
2. Nutritional support
- Avoid dark colored food and drinks
3. Supportive or symptomatic treatment
- anti-emetic, anti-convulsant, antacid, H2-blocker or PPI
4. Daily CBC monitoring
Watch out for Warning Signs
Management in the CRITICAL Phase
 Management in the Convalescence Phase

• Intravenous fluid should be discontinued. In those with massive

effusion and ascites, hypervolemia may occur and diuretic therapy
may be necessary to prevent pulmonary edema.
• Hypokalemia may be present due to stress and dieresis, and should be
corrected with potassium-rich fruits (e.g. banana) or supplements.
 Plan of Management

DIET:
•Diet for age, no dark colored
food
DIAGNOSTICS:
•CBC
•Platelet
 Plan of Management (cont.)
MEDICATIONS:
• Paracetamol 500/tab 1 tab every 4 hours for fever with
temperature of > 37.8 ⁰C
• Ranitidine 50 mg IVTT now then every 8 hours
• Bacillus clausii 1 unit now then OD
• Ig CO sachet 1 sachet dissolve in 20ml water OD
SUPPORTIVE THERAPY:
• Acetate Ringer’s Solution to run 200cc as fast drip then
regulate at 30gtts/min
THANK YOU!