C LINICAL M ANAGEMENT C ONFERENCE

C LINICAL H ISTORY


General Data
   

J.T. , 20-year-old female, single Filipino, Catholic Born on Oct 11, 1990 in Quezon City Currently residing in Salitran, Dasmarinas, Cavite Admitted last Aug 24, 2011 at around 5:26 pm

Chief Complaint


Fever

H ISTORY OF P RESENT I LLNESS



4 days PTA Day 1 of Fever

 

(+) fever - 38.6 C No vomiting, diarrhea, body pains , cough and colds were noted (+) intake of Paracetamol 500mg /tablet 1 tablet every 4 hours temporary relief of fever = 37.3 C Good oral fluid intake and urine output

H ISTORY OF P RESENT I LLNESS



3 days PTA Day 2 of Fever

  

(+) fever persisted = 38 C (+) generalized weakness no vomiting, diarrhea, body pains where noted Took Paracetamol 500mg every 4 hours temporary relief of fever No cough and colds noted

2 days PTC Day 3 of Fever

  

(+) fever persisted 38 C (+) generalized weakness no vomiting, diarrhea, body pains where noted Took Paracetamol 500mg every 4 hours temporary relief No cough and colds noted

1 day PTA Day 4 of Fever

     

(+) persistence of fever, remittent 38-39.2C (+) rashes flat, erythematous, non-pruritic on both upper extremities (+) generalized weakness no vomiting, diarrhea, body pains where noted Took Paracetamol 500mg every 4 hours slight relief (goes down .5-1 C) This prompted the patient to seek medical consult

PAST M EDICAL H ISTORY

    

(-) hypertension (-) diabetes mellitus (-) bronchial asthma (-) known allergies Immunization History

BCG, DPT3, OPV3, Hepa B3, MMR1

Family History
   

(+)HPN mother (+)DM Father, mother (-)asthma (-)allergies

Personal/ Social history

     

Non smoker Non Alcoholic beverage drinker No food preference Recently graduated as a Nurse Lives near a creek Has history of travel to Bicol 1 month PTC

OB-GYN History
     

G0P0 LNMP : 8/22/2011 Regular 28-day cycle Lasting 2-3 days 3-4 pads/day (+)dysmenorrhea

R EVIEW


OF

S YSTEMS

General


(-) weight loss/ weight gain

Skin


(-) dryness, (+) itchiness

HEENT


(-) headache, (-) eye pain, (-) changes in vision, (-) hearing loss, (-) ringing in ears, ()epistaxis, (-) nasal discharge, (-) dysphagia

R EVIEW


OF

S YSTEMS

CVS


(-) chest pain, (-) palpitations, (-) shortness of breath, (-) orthopnea, (-) paroxysmal nocturnal dyspnea

Chest and Lungs



Shortness of breath, (-) pain, (-) sputum

GI


(-) heartburn, (-) diarrhea, (-) constipation, (-) hematemesis, (-) hematochezia, (-) melena

R EVIEW


OF

S YSTEMS

Urinary


(-) nocturia, (-) dysuria, (-) hematuria

Peripheral Vascular


(-) claudication, (-) cramping

Musculoskeletal


(-) muscle or joint pain, (-) cramps, (-) limited range of motion

R EVIEW


OF

S YSTEMS

Neurologic


(-) loss of consciousness, (-) numbness, (-) tingling

Hematologic


(-) easy bruising or bleeding

Endocrine


(-) increased thirst, (-) increased urination, (-) heat or cold intolerance

P HYSICAL E XAMINATION


General Survey


conscious, coherent, oriented to time place and person, not in cardiorespiratory distress

BP: 110/80 HR:90

RR: 18

Temp: 37.3 C

Integument


(+) rashes flat, pruritic, erythematous macules on the upper extremities and on the thighs (-) pallor, (-) jaundice, (-) edema, afebrile, moist with good skin turgor hair is black in color, (-) hair loss (-) nail plate dystrophy, (-) change in shape, (-) color changes (-) nail bed color changes, (-) primary or secondary lesions

HEENT

Head and Neck

symmetrical head, (-) mass, (-) tenderness (-) cervical lymph node enlargement midline trachea thyroid gland not palpable, no tenderness

- thyroid (cartilage) prominence moves with deglutition - full and equal carotid pulses, (-) carotid bruits

Eyes

(+) symmetrical with pink conjunctiva, 3-4mm EBRTL (+) clear cornea, (+) intact visual fields, full extraocular muscle movement

Ears

pinna is mobile (-) masses, ulcerations or tenderness periauricular areas likewise have no swelling or tenderness canal is patent, (-) masses, (-) discharge

Nose

external nose is symmetrical aligned vertically with the midline (-) masses, (-) deformities or tenderness

Oral Cavity and Oropharynx - symmetrical lips, pinkish, devoid of masses or ulcerations - oral mucosa and gums are smooth, pink -(-) lesions, masses or ulcerations - teeth are complete and devoid of caries, stains or plaques - uvula and palate symmetrically rises

Chest and Lungs

Inspection: symmetrical chest w/ symmetrical chest expansion, (-) chest deformity, (-) intercostal space retractions, (-) masses, AP diameter = 2:1 Palpation: equal tactile fremitus Percussion: Resonant on all lung fields Auscultation: equal bronchial and bronchovesicular breath sounds, (-) crackles or wheezes

Cardiovascular

Inspection: (-) precordial bulge Palpation: (-) heaves, (-) thrills, apex beat at the 5th ICS left anterior axillary line Auscultation: normal rate, regular rhythm

Abdomen

Inspection: flat, (-) visible veins, (-) discoloration, pulsations nor peristalsis Auscultation: bowel sounds low-pitched, normoactive, (-) bruit, (-) friction rub Palpation: soft, (-) tender, (-)murphys sign Percussion: tympanitic on all quadrants, liver span is 7cm

Extremities

General: (-) joint pains, (-) difficulty in dressing and walking, able to get out of bed, full and equal peripheral pulses, no atrophy TMJ: (-) redness, mass, swelling, deformity, tenderness, crepitus nor limitation of motion Extremities: (-) tenderness, (-) edema

Neurologic Examination

Mental Status Examination - awake, conscious, responsive, normal stream of talk - appropriate mood, normal attention span - oriented to time, place, and person, does not present with auditory and visual hallucinations

Cranial Nerves
      

Cranial Nerve I no anosmia Cranial Nerve II 2-3 mm EBRTL Cranial Nerve III, IV, VI intact EOMs Cranial Nerve V good masseter tone Cranial Nerve VII - no facial asymmetry Cranial Nerve VIII intact gross hearing Cranial Nerve IX, X intact gag reflex

Cranial Nerve XI good shoulder shrug Cranial Nerve XII tongue is at the midline

Motor: 5/5 in all extremities Sensory: 100% sensation in all extremities Cerebellar Exam - (-) nystagmus, (-) dysmetria, (-) dysdiadokinesia

D IAGNOSTICS /L ABORATORY E XAMS

C HEST X-R AY (8/24/2011)

Unremarkable chest study

U RINALYSIS (8/24/2011)


Yellow, clear, 1.010, pH 6.0, (-) albumin, (-) sugar 0-1 WBC/HPF, 0-1 RBC/HPF Few epithelial cells, few mucus threads

C OMPLETE B LOOD C OUNT

Test Hgb Hct WBC Segs Lymph Eosino Mono Platelet Reference 123-153 G/L 0.36-0.45 4.2-5.4 0.36-0.66 0.22-0.40 0.01-0.04 0.04-0.08 150-450 8/23 135 0.41 2.6 0.64 0.31 0.02 0.01 248 8/24 134 0.41 2.4 0.58 0.37 0.01 0.03 210 8/25 116 0.36 2.6 0.19 0.70 0.05 0.03 202

D IAGNOSTICS
300 250 200 150 100 50 0 Day 3 Day 4 Day 5 Hemoglobin Hematocrit WBC Platelet

D IAGNOSTICS (8/24/2011)
Test Results Reference Range 2.50-7.10 mmol/L 46.00-92.00 mmol/L 137.00-145.00 mmol/L 3.50-5.10 Blood Urea Nitrogen 1.30 L Serum Creatinine Sodium Potassium 55.00 145.00 3.40 L

S EROLOGY FOR D ENGUE T EST

D AY 5
Interpretation of Result IgM Positive IgM and IgG Positive IgG Positive Primary Dengue Infection Secondary Dengue Infection Secondary Dengue Infection

OF

F EVER (8/24/2011)

IgM Negative IgG Positive

R UMPEL -L EEDE C APILLARY F RAGILITY T EST (T OURNIQUET T EST )

D IAGNOSIS
Dengue, Non-Severe, with Warning Sign

Basis:
      

Living in an endemic area Fever Rash Generalized weakness Positive tourniquet test Decreasing platelet count Lethargy

D IFFERENTIAL D IAGNOSES

T YPHOID F EVER
 is a common worldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica, serovar Typhi  Typhoid fever is characterized by a slowly progressive fever as high as 40 C, profuse sweating and gastroenteritis  a rash of flat, rose-colored spots may appear RULE IN High grade fever Body malaise Rashes Leukopenia RULE OUT Cannot be ruled out

M EASLES
 also known as rubeola or morbilli, is an infection of the respiratory system  Symptoms include fever, cough, runny nose, red eyes and a generalized, maculopapular, erythematous rash.

RULE IN High grade fever

RULE OUT Absence of three Cs of measles Coryza, cough, conjunctivitis

Generalized macupopapular erythematous rash

S YSTEMIC V IRAL I NFECTION

RULE IN Fever Body malaise Rashes RULE OUT

C ASE D ISCUSSION : E PIDEMIOLOGY AND T RANSMISSION

D ENGUE E PIDEMIOLOGY


Most rapidly spreading mosquito-borne viral disease in the world An estimated 50 million dengue infections occur annually and approximately 2.5 billion people live in dengue endemic countries

D ENGUE C ASE C LASSIFICATION

1997 WHO C ASE C LASSIFICATION

2009 WHO C ASE C LASSIFICATION

(G ENEVA , S W ITZERLAND , 2008)
Non-Severe Severe

With Warning Signs

Without Warning Signs

N ON -S EVERE D ENGUE WITHOUT WARNING S IGNS



Probable dengue:
 

live in /travel to dengue endemic area Fever and 2 of the following criteria:

Nausea, vomiting Rash Aches and pains Tourniquet test positive Leukopenia

Laboratory-confirmed dengue


(important when no sign of plasma leakage)

D ENGUE WITH WARNING S IGNS

      

Abdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver enlargement >2 cm Laboratory: increase in HCT concurrent with rapid decrease in platelet count

*requiring strict observation and medical intervention

S EVERE D ENGUE


should be considered if the patient is from an area of dengue risk presenting with fever of 27 days plus any of the following features: Severe plasma leakage, leading to:
   

Shock Fluid accumulation with respiratory distress Severe bleeding, as evaluated by clinician Severe organ impairment

Liver: AST or ALT 1000 CNS: impaired consciousness Heart and other organs

T RANSMISSION

T HE V IRUS


A small single-stranded RNA virus comprising four distinct serotypes (DEN-1 to -4). These closely related serotypes of the dengue virus belong to the genus Flavivirus, family Flaviviridae.

T HE V ECTORS


The various serotypes of the dengue virus are transmitted to humans through the bites of infected Aedes mosquitoes, principally Ae. aegypti. A tropical and subtropical species widely distributed around the world The immature stages are found in water-filled habitats, mostly in artificial containers closely associated with human dwellings and often indoors. Aedes albopictus, Aedes polynesiensis and several species of the Aedes scutellaris

T HE H OST
 

Incubation period: 4-10 days Most infections are asymptomatic or subclinical. Primary infection is thought to induce lifelong protective immunity to the infecting serotype. Individuals suffering an infection are protected from clinical illness with a different serotype within 2-3 months of the primary infection but with no long-term crossprotective immunity.

T HE H OST


The dengue virus enters via the skin while an infected mosquito is taking a bloodmeal. During the acute phase of illness the virus is present in the blood and its clearance from this compartment generally coincides with defervescence. Humoral and cellular immune responses are considered to contribute to virus clearance via the generation of neutralizing antibodies and the activation of CD4+ and CD8+ T lymphocytes. In addition, innate host defence may limit infection by the virus. After infection, serotypespecific and cross-reactive antibodies and CD4+ and CD8+ T cells remain measurable for years.

Thrombocytopenia may be associated with alterations in megakaryocytopoieses by the infection of human haematopoietic cells and impaired progenitor cell growth, resulting in platelet dysfunction (platelet activation and aggregation), increased destruction or consumption (peripheral sequestration and consumption).

T RANSMISSION OF THE D ENGUE V IRUS



Dengue virus circulating in the blood of viremic humans is ingested by female mosquitoes during feeding. The virus then infects the mosquito mid-gut and subsequently spreads systemically over a period of 8-12 days.

After this extrinsic incubation period, the virus can be transmitted to other humans during subsequent probing or feeding. The extrinsic incubation period is influenced in part by environmental conditions. Thereafter the mosquito remains infective for the rest of its life.

C LINICAL M ANAGEMENT AND D ELIVERY OF C LINICAL S ERVICES

T HE C OURSE OF D ENGUE I LLNESS

I. F EBRILE P HASE


Patients typically develop high-grade fever suddenly. Usually lasts 27 days Often accompanied by facial flushing, skin erythema, generalized body aches, myalgia, arthralgia and headache. Some patients may have sore throat, injected pharynx and conjunctival injection. Anorexia, nausea and vomiting are common.

F EBRILE P HASE
Difficult to distinguish dengue vs non-dengue febrile diseases in the early febrile phase A positive tourniquet test in this phase increases the probability of dengue. Mild hemorrhagic manifestations like petechiae and mucosal membrane bleeding (e.g. nose and gums) may be seen.

Massive vaginal bleeding (in women of childbearing age) and gastrointestinal bleeding may occur during this phase but is not common . The liver is often enlarged and tender after a few days of fever . The earliest abnormality in the full blood count is a progressive decrease in total white cell count, which should alert the physician to a high probability of dengue.

II. C RITICAL P HASE

 

Around the time of defervescence the temperature drops to 37.538C or less and remains below this level usually on days 37 of illness, an increase in capillary permeability in parallel with increasing hematocrit levels = the beginning of the critical phase. The period of clinically significant plasma leakage usually lasts 2448 hours.

C RITICAL P HASE


Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage. At this point patients without an increase in capillary permeability will improve, while those with increased capillary permeability may become worse as a result of lost plasma volume.

C RITICAL P HASE


The degree of plasma leakage varies. Pleural effusion and ascites may be clinically detectable depending on the degree of plasma leakage and the volume of fluid therapy. Hence chest x-ray and abdominal ultrasound can be useful tools for diagnosis. The degree of increase above the baseline hematocrit often reflects the severity of plasma leakage.

C RITICAL P HASE


The degree of plasma leakage varies. Pleural effusion and ascites may be clinically detectable depending on the degree of plasma leakage and the volume of fluid therapy. Hence chest x-ray and abdominal ultrasound can be useful tools for diagnosis. The degree of increase above the baseline hematocrit often reflects the severity of plasma leakage.

Those who improve after defervescence are said to have non-severe dengue. Some patients progress to the critical phase of plasma leakage without defervescence and, in these patients, changes in the full blood count should be used to guide the onset of the critical phase and plasma leakage.

III. R ECOVERY P HASE



If the patient survives the 2448 hour critical phase, a gradual reabsorption of extravascular compartment fluid takes place in the following 4872 hours. General well-being improves, appetite returns, gastrointestinal symptoms abate, hemodynamic status stabilizes and diuresis ensues. Some patients may have a rash of isles of white in the sea of red Some may experience generalized pruritus. Bradycardia and electrocardiographic changes are common during this stage.

RECOVERY PHASE


The hematocrit stabilizes or may be lower due to the dilutional effect of reabsorbed fluid. White blood cell count usually starts to rise soon after defervescence but the recovery of platelet count is typically later than that of white blood cell count. Respiratory distress from massive pleural effusion and ascites will occur at any time if excessive intravenous fluids have been administered. During the critical and/or recovery phases, excessive fluid therapy is associated with pulmonary edema or congestive heart failure.

C LINICAL P ROBLEMS IN THE D IFFERENT P HASES OF D ENGUE

1 Febrile phase Dehydration; high fever may cause neurological disturbances and febrile seizures in young children Shock from plasma leakage; severe haemorrhage; organ impairment Hypervolemia (only if intravenous fluid therapy has been excessive and/or has extended into this period)

2 Critical Phase 3 Recovery phase

S EVERE D ENGUE


Defined by one or more of the following:



plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation, with or without respiratory distress, and/or severe bleeding, and/or severe organ impairment

Progression of vascular permeability worsening of hypovolemia Initial stage of shock



Compensatory mechanism produces tachycardia and peripheral vasoconstriction reduced skin perfusion cold extremities and delayed capillary refill time

The patient is considered to have shock



If the pulse pressure is equal or less than 20 mmHg in children He/she has signs of poor capillary perfusion

Cold extremities, delayed capillary refill, rapid pulse rate

Severe dengue should be considered if the patient is from an area of dengue risk presenting with fever of 27 days plus any of the following features: There is evidence of plasma leakage, such as:
  

high or progressively rising hematocrit; pleural effusions or ascites; circulatory compromise or shock (tachycardia, cold and clammy extremities, capillary refill time greater than three seconds, weak or undetectable pulse, narrow pulse pressure or, in late shock, unrecordable blood pressure).

There is significant bleeding. There is an altered level of consciousness (lethargy or restlessness, coma, convulsions). There is severe gastrointestinal involvement (persistent vomiting, increasing or intense abdominal pain, jaundice). There is severe organ impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy) or other unusual manifestations.

R ECOMMENDATIONS T REATMENT

FOR

A S TEPWISE A PPROACH IN THE M ANAGEMENT OF D ENGUE

Overall assessment

Step 1

Diagnosis, assessment of disease phase and severity Step 2

Step 3

Management

S TEP 1: O VERALL A SSESSMENT



History
      

date of onset of fever/illness; quantity of oral intake; assessment for warning signs (Textbox C); diarrhoea; change in mental state/seizure/dizziness; urine output (frequency, volume and time of last voiding); other important relevant histories, such as family or neighborhood dengue,

H ISTORY
Parameters Date of onset of fever/illness Quantity of Oral Intake Assessment of Warning signs Patient 5 days PTC >2L of water/day Abdominal Pain Ongoing vomiting Liver enlargement Mucosal bleeding High hematocrit with low platelets Lethargy

H ISTORY
Parameters Change in mental state Urine Output NONE Patient claims to have no changes in urination. (-) anuria (-) dysuria (-)dribbling Patient

Temperature
38.8 38.6 38.4 38.2 38 37.8 37.6 37.4 37.2 37 36.8 Day 1Day 2Day 3Day 4Day 5Day 6

Temperature

S TEP 1: O VERALL A SSESSMENT



History (continued)


travel to dengue endemic areas, coexisting conditions (e.g. infancy, pregnancy, obesity, diabetes mellitus, hypertension), jungle trekking and swimming in waterfall (consider leptospirosis, typhus, malaria), Recent unprotected sex or drug abuse (consider acute HIV seroconversion illness).

S TEP 1: O VERALL A SSESSMENT



Physical Examination
  

assessment of mental state; assessment of hydration status; assessment of hemodynamic status (Textbox D); checking for tachypnea/acidotic breathing/pleural effusion;

S TEP 1: O VERALL A SSESSMENT



Physical Examination


checking for abdominal tenderness/hepatomegaly/ascites; examination for rash and bleeding manifestations; tourniquet test (repeat if previously negative or if there is no bleeding manifestation).

P HYSICAL E XAMINATION
Parameters Assessment of Mental state Assessment of Hydration status Patient Patient is awake, conscious, coherent; Oriented to time person and place; (-) pallor; (-) pale palpebra; (-) dry oral mucosa

Checking for Patient had normal breathing rate and tachypnea/acidotic pattern; Breath sounds were clear in breating/ pleural effusion both lung fields; Vocal fremitus were resonant in both dull fields; Symmetrical chest expansion

Parameters Examination of Rash and Bleeding manifestations Tourniquet Test

Patient Generalized macular rashes on patients upper and lower extremities, chest, and back

S TEP 1: O VERALL A SSESSMENT



Investigation
 

CBC with platelet count on first visit Other tests

Liver function test

Glucose Serum electrolytes Urea and creatinine Bicarbonate or lactate Cardiac enzymes ECG Urine specific gravity

T REATMENT A CCORDING TO G ROUPS A-C



Group A
 

patients who may be sent home able to tolerate adequate volumes of oral fluids and pass urine at least once every six hours, and do not have any of the warning signs, particularly when fever subsides

T REATMENT A CCORDING TO G ROUPS A-C



Group B
  

Patients who should be referred for inhospital management patients with warning signs those with co-existing conditions that may make dengue or its management more complicated pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic haemolytic diseases), those with certain social circumstances (such as living alone, or living far from a health facility without reliable means of transport).

T REATMENT A CCORDING TO G ROUPS A-C



Group C


patients who require emergency treatment and urgent referral when they have severe dengue All patients with severe dengue should be admitted to a hospital with access to intensive care facilities and blood transfusion. Judicious intravenous fluid resuscitation is the essential and usually sole intervention required.

M ANAGEMENT

IN THE

ER
 

CBC with Platelet Count Advised Admission

M ANAGEMENT IN THE WARDS

   

Diet as tolerated Monitor VS q4, I and O q shift and record IVF: D5LR 1L x 8 hours Diagnostics:
     

CBC with PC Na, K, BUN, Crea CBG = 110 CXR, UA Salmonella IgG, IgM Dengue Blot Test

T HERAPEUTICS


Paracetamol 500 mg/tablet 1 tablet q4 for T > or = to 37.8C Paracetamol 300 mg IV q4 for T>38.5C Multivitamins capsule OD

R EFERENCE


WHO Dengue Guidelines for Diagnosis, Treatement, Prevention and Control 2009