Admission Conference

University of Perpetual Help Dr. Jose G. Tamayo Medical University

College of MedicineDepartment of Medicine

24-Hour Duty• Patients seen: 8• Admissions: 4

•Direct Admission: 1• ER Admission: 3

• THOC: 0• DAMA: 0• Mortality: 1

General Data• This is a case of A.S., a 27-year old

female, married, Filipino, Roman Catholic, born on March 13, 1988, currently residing in Barangay Sto. Tomas, Biñan, Laguna, was admitted for the first time in our institution on December 1, 2015.

Chief Complaint

• Fever x 3 days

• Reliability: 90%• Informant: Patient

History of Present Illness• 3 days PTC

– (+) fever (Tmax 38.7oc)– (+) vomiting, (-) ~half cup/bout, blood-streaked,

previously ingested food x 3 bouts– (+) headache, 8/10, continuous, bilateral,

frontoparietal area, throbbing, non-radiating– (+) muscle and joint pains– (+) epgastric pain, 6/10, dull in character, not

influenced by food intake, non-radiating– (-) colds, (-) cough, (-) dysuria, (-) flank pain,

(-) nose/gum bleed, (-) melena– Self-medicated with Paracetamol 500mg/tab

which afforded temporary relief from fever

History of Present Illness• 2 days PTC– Still with above symptoms– Now (+) vomiting, non-blood tinged, ~half

cup/bout, previously ingested food x 2– Fever was relieved temporarily by Paracetamol

• Few hours PTC– Still with above symptoms– Now (+) vomiting, non-blood tinged, ~half

cup/bout, previously ingested food x 4– Persistence of fever prompted the patient to

seek consult in our institution, hence admission

Past Medical History• (-) Hypertension• (-) Diabetes mellitus• (-) Bronchial asthma• (-) Pulmonary tuberculosis• (-) Thyroid disease• (-) Liver / kidney disease• (-) Previous hospitalization / surgery• (-) Allergy to food / drug

Family History• (+) Breast cancer, maternal side• (+) Colon cancer, maternal side

Personal & Social History• (-) Smoker• (-) Alcoholic beverage drinker• (-) Illicit drug use

OBGYN History• OB score: G2P3 (3003)• Menarche: 11 years old• Interval: regular (28 to 30 days)• Duration: 5 – 7 days• Amount: 5 – 6 moderately soaked

ppd• (-) Dysmenorrhea• LMP: Nov. 27, 2015 (5th day menses)

Review of Systems• General: (-) weight loss / gain, (-) easy fatigability• Integumentary: (-) rash, (-) pruritus, (-) skin color changes• HEENT: (-) eye redness, (-) colds, (-) ear pain, (-) sore throat• Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis• Cardiovascular: (-) chest pain, (-) palpitation, (-) orthopnea• Gastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-)

hematochezia• Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-)

hematuria• Endocrinologic: (-) polyuria, (-) polydipsia, (-) heat / cold

intolerance• Hematologic: (-) easy bruisability, (-) bleeding tendencies• Neurologic: (-) dizziness, (-) seizures, (-) loss of consciousness

Physical Examination• General Survey: Conscious, coherent,

ambulatory, not in cardiorespiratory distress• Vital Signs:– BP: 110/70 mmHg– HR: 103 bpm– RR: 19 cpm– Temp: 36.7oC– O2 sat: 98%– Weight: 125 lbs– Height: 5’2”– BMI: 22.86 kg/m2 (normal)

Physical Examination• Skin: Warm to touch, good skin turgor• HEENT: Anicteric sclerae, pink palpebral

conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervicolymphadenopathy

• Chest & Lungs: Symmetrical chest expansion, no retraction, clear breath sounds

• Heart: Adynamic precordium, no murmumr, tachycardic, regular rhythm

Physical Examination• Abdomen: Flabby abdomen, normoactive

bowel sound, soft, (+) direct epigastric tenderness, (-) kidney punch test

• Extremities: Grossly normal extremities, no edema, no cyanosis, full and equal pulses

Neurologic Examination• Cerebral: Awake, alert, oriented to time,

place, person• Cerebellar: Able to perform rapid

alternating movement and finger-to-nose tests with ease

• CN I: Able to smell• CN II, III: Pupils equally round, reactive to

light and accomodation• CN III, IV, VI: Intact extraocular muscles• CN V: Able to clench jaw

Neurologic Examination• CN VII: No facial asymmetry• CN VIII: Able to hear• CN IX, X: Uvula at midline, swallows with

ease• CN XI: Good shoulder shrug• CN XII: Tongue at midline upon protrusion

Neurologic ExaminationMOTOR SENSORY DEEP TENDON REFLEX

5/5 5/5

5/55/5

100%100%

100%100%

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Salient FeaturesHISTORY PHYSICAL EXAMINATION

• 27-year old female• 3-day history of intermittent

fever• Associated symptoms: Persistent vomiting Headache Muscle and joint pains Epigastric pain• Negative symptoms: No bleeding tendency No dysuria No flank pain No cough and colds

• Afebrile (36.7oC)• Normotensive (110/70 mmHg)• Tachycardic (103 bpm)• Dry lips• Clear breath sounds• Direct epigastric tenderness• Negative kidney punch test• Full and equal pulses

Differential DiagnosisURINARY TRACT INFECTION

RULE IN RULE OUT(+) Fever (-) Dysuria

(+) Abdominal pain (-) Kidney punch test(+) Vomiting

TYPHOID FEVER(+) Abdominal pain Short duration of fever

(+) Vomiting Intermittent type of fever(+) Fever

CHIKUNGUNYA(+) Intermittent fever Join pains not so severe

(+) Joint pains

Admitting Impression

T/C Dengue fever syndrome

CBC w/ platelet countParameters

Admission

6:00 AM Parameters

Admission

6:00 AM

Hemoglobin

117 111 Monocytes

0.09 0.10

Hematocrit

0.38 0.36 Basophils 0.01 0.01

RBC count 4.70 4.39 MCV 81.5 80.9WBC count

2.97 1.93 MCH 24.9 25.3

Segmenters

0.71 0.62 MCHC 306 315

Lymphocyte

0.19 0.27 Platelet 224 199

UrinalysisParameter Values Parameter Values

Color Light yellow Pus cells 1 – 3 / hpfTransparency Slightly hazy RBC 6 – 8 / hpfpH 6.5 Epithelial cells FewProtein Trace Mucus threads FewGlucose Negative Bacteria OccasionalSpecific gravity 1.010

Dengue Duo• Dengue NS1 = Positive• Dengue IgM = Negative• Dengue IgG = Negative

Blood ChemistryParameter Values

Sodium 138.20 mmol/LPotassium 3.33 mmol/L

SGPT 20.50 U/L

Plan• Diet: DAT, avoid dark colored foods• IVF: PNSS 1 L @ 170 cc/hr• Investigations:

• CBC w/ PC• Dengue NS1 and Duo• Urinalysis• Na, K• SGPT

• Therapeutics:• Paracetamol 500 mg/tab 1 tablet Q4 PRN T > 37.8oC • Paracetamol 300 mg/tab IV Q4 PRN T > 38.5oC • Omeprazole 40 mg/tab 1 tablet ODBB• Metoclopramide 1 amp IV Q8 PRN for nausea and

vomiting

Dengue Fever

Etiology• Vectors: Aedes aegypti and Aedes

albopictus• Family: Flaviviridae• Genus: Flavivirus• Serotypes: DEN-1 upto DEN-4

Epidemiology• Dengue is the most rapidly spreading

mosquito-borne viral disease in the world

• Estimated 50 million dengue infections occur anually

• Dengue has been reported predominantly among urban and peri-urban populations where high population density facilitates transmission

Pathophysiology• Incubation period: 4 – 10 days• Plasma leakage, hemoconcentration,

homeostasis abnormalities characterize severe dengue

• Endothelial activation, rather than destruction, mediate plasma leakage via activation of infected monocytes, T cells, complement system and inflammatory mediators

Pathophysiology• Thrombocytopenia is associated with

alterations in megakaryocytopoiesis by infection of human hematopoietic cells and impaired progenitor cell growth

• This results in platelet dysfunction, increased platelet destruction or consumption

• Hemorrhage is a consequence of thrombocytopenia, platelet dysfunction, or disseminated intravascular coagulation

Clinical Manifestations& Dengue Classifications

Clinical Manifestations

Clinical Manifestations

Clinical Manifestations

Course of the Disease

Febrile Phase• Acute febrile phase lasts 2 – 7 days• A positive tourniquet test may

increase the probability of dengue• Mild hemorrhagic manifestations like

petechiae and mucosal membrane bleeding may be seen

• The earliest abnormality in the CBC is progressive decrease in WBC

Critical Phase• Occurs on the 3rd up to the 7th day of illness• Lasts for 24 – 48 hours• Increased capillary permeability• Increasing hematocrit (hemoconcentration)• Shock occurs when a critical volume of plasma

is lost through leakage (preceded by warning signs)

• Those who improve after defervescence are said to have non-severe dengue

• Some patients progress to the critical phase of plasma leakage without defervescence. In such case, changes in CBC is used to guide the onset of critical phase and plasma leakage

Recovery Phase• Gradual reabsorption of

extravascular compartment fluid takes place following 48 to 72 hours

• Herman’s rash, generalized pruritus, and bradycardia are common during this stage

• Fluid overload is to be watched out during this phase of dengue

Treatment• Fluids is the mainstay of treatment

for patients with dengue with or without warning signs

Treatment• Dengue with warning signs

• 5 – 7 ml/kg/hr for 1 – 2 hours• 3 – 5 ml/kg/hr for 2 – 4 hours• 2 – 3 ml/kg/hr according to clinical

response• Reassess clinical status and repeat Hct• If Hct is the same or rises minimally, continue

the same rate for 2 – 4 hours• If VS worsens with rising Hct, increase rate to 5

– 10 ml/kg/hr for 1 – 2 hours.