dengue fever with warning signs. objectives to identify warning signs seen in dengue fever to manage...
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Dengue Fever with Warning Signs
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Objectives
To identify warning signs seen in Dengue Fever
To manage a case of Dengue Fever with warning signs
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General Data
• J.M.G• 6 years old• Male• Pasig City
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Chief Complaint
• Fever of 2 days duration
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HPI
• (+) Fever, highest recorded temperature: 39.7C
• No other signs and symptoms noted
2 days PTA
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HPI
• (+) Episodes of fever unrelieved by paracetamol
• Accompanied by headache• One episode of loose stools• One episode of vomiting• Decreased appetite
Day of Consult
ER Consult
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HPI• HR 118 RR 24 T 38.8 BP 90/60• CBC was done• Dengue NS1 done: (+)• Flushed• Slightly sunken eyeballs, moist
mucosa• Clear breath sounds• Regular cardiac rhythm• Soft non- tender abdomen• Full and equal pulses
At the ER
Admission
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Review of Systems
• Headache• No cough and colds, no weakness, no joint
pains, no difficulty of breathing, no nausea or vomiting, no abdominal pain, no change in stool color
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Past Medical History• Asthma, last attack 2013, no maintenance
medications• No known allergy to food and medication
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Family History
• Hypertension (paternal)• Diabetes Mellitus• Asthma
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Birth and Nutritional History
• Born full term via NSD to a 26 year old G1P1• Birth weight 2.58 kg (AGA)• No perinatal/neonatal complications
• Not breast fed, Enfalac, Weaned by 6 months, • Current diet consist of rice, meat, fish and
vegetables
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At the Floors
General Survey: Conscious, alert, coherent, not in cardiorespiratory distress
• Ht: 143 cm• Wt: 38.5• BP: 100/60• HR: 106• RR: 24• Temp: 38.1 C
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• HEENT: anicteric sclerae, pink palpebral conjunctiva, no TPC, no nasal discharge, (-) CLADs,
• Chest/Lungs: symetric chest expansion, clear breath sounds, no rales and wheezes
• Adynamic precordium, Apex beat 4th ICS MCL, normal rate, regular rhythm, no murmurs
• ABDOMEN: Flat, normoactive bowel sounds, soft, (–) tenderness, (-) masses
• Extremities: full and equal pulses, (-) edema, (-) cyanosis, good skin color and turgor, CRT<2 sec
• Skin: no rashes, no petechiae
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Salient Features
• 7/M• 2 day history of fever• (+) headache• No recurrence of vomiting or loose stools• No bleeding, no rashes, no petechiae• No hemodynamic compromise• Dengue NS1 (+)
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Admitting Diagnosis
Dengue Fever without Warning signs ( WHO 2010)
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Day 4 in the hospital (Day 5 of illness)
S> Day 1 afebrileNo recurrence of epistaxis(+) abdominal painNo vomiting episodes
O> Awake, comfortable, flushedClear breath soundsRegular cardiac rhythm(+) abdominal tenderness
epigastric, no liver enlargement Full and equal pulses, warmextremities, CRT< 2 sec
A> Dengue Fever with Warning Signs
P> Increase hydration to 5- 7 cc/kg/hrSerial CBC monitoringSGOT, SGPTEsomeprazoleChest Xray
FOR PICU TRANSFER
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Day of Illness Hgb Hct WBC Platelet Count
Day 2 134 40 4.4 157
Day 3 128 38 3 116
Day 4a 135 42 1.7 110
Day 4b 151 45 3.7 72
Day 5a 156 47 3.7 70
Day 5b 158 48 43.2 70
Day 5c 159 48 4.6 70
Day 5d 152 46 5 70
Day 6a 155 47 5.2 94
Day 6b 147 43 4.1 96
Day 7 92 27 2.8 120
Na 130 (135-145) Crea 0.47 (0.52- 0.72)K 4 (3.5- 5.1) SGPT 228 (9-68)iCal 4.64 (4.48 – 5.28) SGOT 314 (5-34)
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Chest Xray
Pleural Effusion, RIGHT
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CASE definition: WHO 2010, Interim PPS 2010
Dengue w/o warning signs
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Problems at the PICU
• Hemoconcentration Fluid support Serial CBC monitoring
• Pleural effusion Fluid titration
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Management: Group B: (with warning signs)in hospital
Treatment:Increase oral fluid intakeIV fluids (0.9% saline, LR)
Monitor: Temperature Pattern
Fluid intake and lossesUrine outputWarning signsHCT, platelet, WBC
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Indications for Hospital Discharge
• Absence of fever for 24 hours (without anti-fever therapy) and return of appetite
• Visible improvement in clinical picture• Stable hematocrit• 3 days after recovery from shock• Platelets ³ 50,000/mm3
• No respiratory distress from pleural effusions/ascites
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Sources
• WHO Dengue Guidelines on Treatment, Diagnosis, Prevention, and Control 2009
• Philippine Pediatric Society interim guidelines on Dengue 2010