Dengue Fever with Warning Signs

Dengue Fever with Warning Signs

Objectives • To identify warning signs seen in Dengue Fever • To manage a case of Dengue Fever with warning signs

General Data • J.M.G • 6 years old • Male • Pasig City

Chief Complaint • Fever of 2 days duration

HPI 2 days PTA • (+) Fever, highest recorded temperature: 39.7C • No other signs and symptoms noted

HPI Day of Consult • (+) Episodes of fever unrelieved by paracetamol • Accompanied by headache • One episode of loose stools • One episode of vomiting • Decreased appetite ER Consult

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

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

Past Medical History • Asthma, last attack 2013, no maintenance medications • No known allergy to food and medication

Family History • Hypertension (paternal) • Diabetes Mellitus • Asthma

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

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

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

Salient Features • 7/M • 2day history of fever • (+) headache • No recurrence of vomiting or loose stools • No bleeding, no rashes, no petechiae • No hemodynamic compromise • Dengue NS1 (+)

Admitting Diagnosis Dengue Fever without Warning signs ( WHO 2010)

Day 4 in the hospital (Day 5 of illness) S> Day 1 afebrile No recurrence of epistaxis (+) abdominal pain No vomiting episodes O> Awake, comfortable, flushed Clear breath sounds Regular cardiac rhythm (+) abdominal tenderness epigastric, no liver enlargement Full and equal pulses, warm extremities, CRT< 2 sec A> Dengue Fever with Warning Signs P> Increase hydration to 5- 7 cc/kg/hr Serial CBC monitoring SGOT, SGPT Esomeprazole Chest Xray FOR PICU TRANSFER

Chest Xray Pleural Effusion, RIGHT

CASE definition: WHO 2010, Interim PPS 2010 Dengue w/o warning signs

Problems at the PICU • Hemoconcentration • Fluid support • Serial CBC monitoring • Pleural effusion • Fluid titration

Management: Group B: (with warning signs)in hospital Treatment: Increase oral fluid intake IV fluids (0.9% saline, LR) Monitor: Temperature Pattern Fluid intake and losses Urine output Warning signs HCT, platelet, WBC

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

Sources • WHO Dengue Guidelines on Treatment, Diagnosis, Prevention, and Control 2009 • Philippine Pediatric Society interim guidelines on Dengue 2010

Dengue Fever with Warning Signs