CASE PRESENTATION

Sunita M. Dubb-Padilla M.D.

Dept. of Pediatrics
GENERAL DATA
M.J., 13 years old , Female, Filipino, Catholic
Presently residing at 9A Ka Tony Bautista St.,
Palasan, Valenzuela City
Admitted for the 1st time in our institution
CHIEF COMPLAINT
FEVER
HISTORY OF PRESENT ILLNESS
4 days PTC (+) on and off fever , (+) Headache
No consult done
Given Paracetamol 500 mg tab, 1 tab (15 mkdose) q4 hours

3 days PTC (+) fever (+) headache (+) Abdominal Pain
Consulted at local health center dx: ATP
Given Amoxicillin 50mkday and Paracetamol 15mkdose
1 day PTC (+) fever (+) abdominal pain (+) lbm 3x watery non-bloody
No consult was done, patient continued medications given

Few hours PTC Still with above symptoms which prompted consult hence
admission
PAST MEDICAL HISTORY
Incomplete Vaccination
BCG 1 dose
Hepa B 3 doses
OPV 3 doses
DPT 3 doses
Measles (-)
(-) measles (+) mumps (-) chicken Pox
No previous hospitalization
FAMILY HISTORY
(+) Asthma - Maternal
(+) HPN - Maternal
(-) DM
(-) Cancer
(+) PTB Maternal grandmother 2007

PERSONAL AND SOCIAL HISTORY
2
nd
among 7 siblings living with parents in a
house being taken care of by her mother,
father is a laborer.
Patient is a 2nd year high school student at
Pulo National High School
Non-smoker, non-alcoholic beverage drinker
REVIEW OF SYSTEMS
General: dec. Appetite, body malaise
HEENT: (-) epistaxis (+) sore throat
Chest & Lungs: (-) cough (-) colds
Cardiovascular : (-) orthopnea (-) DOB
Abdomen: pain epigastric area
Gastro-Intestinal: (+) LBM (-) constipated (-) vomiting
Genito-Urinary: (-) dysuria
Female Reproductive: unremarkable
Nervous: unremarkable
PHYSICAL EXAMINATION
General Survey: conscious, coherent, afebrile, not in respiratory distress
Vital Signs: BP: 100/70 HR: 94bpm RR: 25 cpm Temp:
37.3 C Wt : 33kgs
Skin: warm, (+) rashes lower and upper extremitties
HEENT: normocephalic, no head lesions, pink palp conjuctiva, Anicteric
Sclera, (-) no sunken, (-) Tonsillopharyngeal congestion, (-) no oral
ulceration
Neck: supple, (-) CLAD
Chest & Lungs: Symmetrical Chest Expansion, Clear Breath Sounds, (-)
retractions
Cardiovascular: Adynamic precordium, NRRR, (-) murmur
Abdomen: Globular, Soft, tender, 5 bowel sounds/min, not palpable spleen,
liver not palpated
Rectum: unremarkable
Female Reproductive : unremarkable
Extremeties: Full & equal pulses, (-) cyanosis (-) edema (+) hermans rash
Neurologic: Conscious, Coherent, Oriented to 3 spheres
No motor nor sensory deficits noted
DIFFERENTIAL DIAGNOSES
RULE IN

RULE OUT

Typhoid Fever (+) Abdominal Pain
(+) Fever
(+) LBM
(-) rose spots
(+) Hermans Rash on
extremeties
Low WBC ct.
Viral Exanthem
( German Measles)
(+) Fever
(+) Headache
(+) Body Malaise

(-) Characteristic of Rash

DHF (+) Fever
(+) Headche
(+) Abdominal Pain
(+) Hermans Rash on
extremeties


TYPHOID FEVER
Other names: Enteric Fever, Bilious Fever ,Yellow Jack
Causative Agent Salmonella Typhi
3 main antigenic factors: the O, or somatic antigen the Vi, or
encapsulation antigen the H, or flagellar antigen
Epidemiology World: 17 million cases per year U.S.: 400
cases per year (70% in travelers) Philippines: (Nov 2006)
478 in Agusan del Sur; (May 2004) 292 in Bacolod City
Mode of Transmission Ingestion of contaminated food or
water; rarely from person to person transmission through
fecal-oral route
Incubation Period First 7-14 days after ingestion
Symptoms Diarrhea may occur Active infection,
Severe Headache, Generalized Abdominal Pain or
Anorexia
Fever - Intermittent [usually higher in the evening]
Pathognomonic Sign Rose Spots Blanching pink
macular spots 2-3 mm over trunk
Diagnostics:
Diagnostics CBC -normal WBC (despite fever), platelet count
Tourniquet Test
Typhi dot test (if illness is 4 days or longer)
GERMAN MEASLES
Rubella (German measles) is a worldwide, mild,
exanthematous and highly infectious viral disease
of children in unvaccinated populations.
The rubella virus is a RNA virus and belongs to the
genus Rubivirus and the family Togaviridae.
Rubella is transmitted by direct contact or droplet
spread similar to the transmission of measles.
The incubation period is 1320 days.

Rubella is typically a mild disease with few complications,
and infections go unrecognised or are asymptomatic.
Children usually have few or no constitutional symptoms but
adults may experience a 15 days prodrome of fever,
malaise, headache and arthralgia.
The typical presentation of rubella is a transient,
erythematous maculo-papular rash that starts in the face,
becomes generalised over 24 hours and lasts for about
three days.
Enlarged post-auricular and sub-occipital lymph nodes,
which precede the rash, are characteristic of rubella and last
for 58 days.
There is no specific treatment for rubella. Treatment should
be symptomatic.


ADMITTING DIAGNOSIS
Dengue Hemorrhagic
Fever I
UPON ADMISSION:
Patient was hooked to PNSS 1L to run at TFR (5)
Diagnostics:
CBC with APC
Urinalysis
PT, PTT
Medications given:
Paracetamol 500mg tab, 1 tab q4 PRN for temp 37.8 C
(15 mkdose)
Omeprazole 20mg TIV OD
Ancillaries
TSB for fever
Vital signs monitored every 4 hours
WOF: sign of bleeding, hypotension

PROGRESS NOTES
HD1 HD2 HD3
Fever

A1-2 A2-3 A3
Abdominal pain (+) (-) (-)
Headache (-) (-) (-)
Appetite dec inc inc
Management IVF D5LR (3)
CBC c APC OD
ORS
Omeprazole OD
IVF D5LR (3)
CBC c APC OD
ORS
Omeprazole OD

MGH
H/M : Multivitamins tab OD
Ascorbic Acid 500 mg tab
OD
Opd ff-up after 5 days
LABORATORY RESULTS
CBC with APC
1-8-12 1-9-12 1-10-12 1-12-12
Hbg: 113 Hbg: 113 Hbg: 116 Hbg: 112
Hct: 36.1 Hct: 34.5 Hct: 35 Hct: 35
RBC: 4.20 RBC: 3.99 RBC: 4.01 RBC: 4.07
WBC: 4.0 WBC: 4.3 WBC: 5.4 WBC: 6.5
L : 51.4 L : 54.9 L : 54.4 L : 46.8
Mo: 12.4 Mo: 7.9 Mo:4.6 Mo:6.4
Gr: 36.2 Gr: 37.2 Gr: 41.06 Gr: 44.8
Eo: Eo: Eo: Eo:
Pl: 160 Pl: 160 Pl: 203 Pl: 218
Urinalysis
1-9-12 1-11-12
Color: Yellow YELLOW
Trans.: Sl. Cloudy SL.CLOUDY
Reaction: Ph 5.0 5.0
Sp. Grav. 1.015 1.010
RBC: 4-6 0-1
Pus: 15-20 0-1
Casts: (-) (-)
Albumin Trace (-)
Sugar: (-) (-)
Crystals: Rare (-)
Epithelium: few (-)
PT, PTT:
Pt = 12.5
% = 106.4
INR = .93
APTT: 38.2

DENGUE FEVER & DENGUE
HEMORRHAGIC FEVER
BACKGROUND
Dengue fever (DF) and Dengue Hemorrhagic
Fever (DHF)/Dengue Shock Syndrome
(DSS) continue to be significant causes of
morbidity and mortality in the Philippines.
Dengue is considered to be endemic in the
Philippines with clustering of cases and
outbreaks occurring at unpredictable
intervals due to inability to control and
prevent this arthropod-borne disease.
Vector mosquito Aedis Aegypti , Aedis albopictus,
INCUBATION PERIOD UNCERTAIN. Probably 6
days to 1 week
PERIOD OF COMMUNICABILITY Unknown.
Presumed to be on the first week of illness when
virus is still present in the blood.
Occurrence is sporadic through out the year.
Epidemic usually occur during the rainy seasons
June November. Peak months are September
and October.

SYMPTOMS
High grade fever
Abdominal pain
Headache
Flushing
Vomiting
Conjunctival infecting
Epistaxis or other signs of bleeding
LABORATORIES
CBC with APC
PT, PTT
Serologic Tests:
HI (Hemagglutin Inhibition Test)
Dengue Dipstick ELISA
IgM antibody enzyme immunoassay
Dengue Dot Blot
Dengue Ns1Ag rapid early dx of dengue (day 1-4 of illness)


DENGUE CLASSIFICATION
CURRENT WHO Case Definition of Dengue and
Levels of Severity (1997) as adapted by the PPS
Clinical Practice Guidelines on Dengue 2008
PROPOSED WHO Classification and Levels of
Severity 2009
Case Definition for Dengue Fever
Probable:
an acute febrile illness with 2 or more of the following:
Headache
Retro-orbital pain
Arthralgia
Rash
Hemorhagic manifestations
Leukopenia; AND
Supportive serology ( a reciprocal HI antibody titer >
1280, a comparable IgG assay ELISA titer or (+) IgM
antibody test on a late or acute convalescent phase
serum specimen
Confirmed:
A case confirmed by laboratory criteria
Nonsevere Dengue without Warning signs
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
Case Definition for Dengue Hemorrhagic Fever
(DHF)
The following must all be present:
1. Fever, or history of fever, lasting for 2-7 days, occasionally biphasic
2. Hemorrhagic tendencies evidenced by at least one of the following:
a. (+) tourniquet test
b. Petechiae, ecchymosis, purpura
c. Bleeding from the mucosa, GIT

Nonsevere Dengue without Warning signs
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) injection sites or other locations
d. Hematemesis or melena

3. Thrombocytopenia ( 100,000 cells/mm3 or less)
4. Evidence of plasma leakage due to increased vascular permeability, manifested
by at least one of the following:
a. A rise in the hematocrit equal to or greater than 20% above average for age, sex, and
population
b. A drop in the hematocrit following:volume replacement treatment equal to or greater than 20%
of baseline
c. Signs of plasma leakage such as pleural effusion, ascites and Hypoproteinemia
Grading of Severity of DHF/DSS
DHF Grade 1
Fever accompanied by non-specific
constitutional
signs and symptoms such as
anorexia, vomiting, abdominal pain;
the only hemorrhagic manifestation
is a (+) tourniquet test and/or easy
bruising
Nonsevere Dengue with or without
Warning signs
Fever and 2 of the following criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leukopenia
Any warning sign*
DHF Grade 2
Spontaneous bleeding in addition to
manifestations of grade 1 patients
usually in the form of skin or other
hemorrhages ( mucocutaneous), GIT
Dengue with Warning signs*:
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
DHF Grade 3 (DSS)
Circulatory failure manifested by
rapid,weak pulse
and narrowing of pulse pressure or
hypotension, with
the presence of cold clammy skin and
restlessness

DHF Grade 4 (DSS)
Profound shock with undetectable blood
pressure or pulse
All of the four criteria for DHF must be
present ,
plus evidence of circulatory failure
manifested by:
Rapid and weak pulse, AND
Narrow pulse pressure ( < 20mmHg
[2.7kPa]
OR
manifested by:
Hypotension for age, AND
Cold clammy skin and restlessness
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:
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
FLUID MANAGEMENT OF DENGUE FEVER AND DENGUE
HEMORRHAGIC FEVER
A. Fluid management for patients with DF/DHF [Dengue without warning signs]
who are
not admitted.
In patients with DF/DHF Grade I who are not admitted, oral rehydration solution should
be given as follows based on weight, using currently recommended ORS:










Reduced osmolarity ORS containing sodium 45 to 60 mmol/liter.
Sports drinks [Na] <20 meqs/should not be given.
(Ludan Method)
Body Weight (kg) ORS to be given
> 3-10 100ml/kg/day
> 10-20 75ml/kg/day
>20-30 50-60ml/kg/day
> 30-60 40-50ml/kg/day
Fluid management for patients who are admitted, without shock (DF/DHF Grade I-II or Dengue
without warning signs).
Isotonic solutions (D5 LRS, D5 Acetated Ringers D5 NSS/ D5 0.9 NaCl) are appropriate for DHF patients
who are admitted but without shock.
Maintenance IVF is computed using the caloric-expenditure method (Halliday and Segar Method) or
Calculation Based on Weight (Ludan Method)
Holiday and Segar Method
Body Weight (kg) Total Fluid Requirement (ml/day)
0-10 100 ml/kg
>10-20 1,000 ml + 50 ml/kg for each kg >10
>20 1,500 ml + 20 ml/kg for each kg >20
If the patient shows signs of mild dehydration but is NOT in shock, the volume needed for mild
dehydration is added to the maintenance fluids to determine the total fluid requirement (TFR).

The following formula may be used to calculate the required volume of intravenous fluid to infuse:
TFR = Maintenance IVF + Fluids as for Mild dehydration

Where the volume of fluids for mild dehydration is computed as follows:
Infant 50 ml/kg
Older Child or Adult 30 ml/kg

One-half of the computed TFR is given in 8 hours and the remaining one-half is given in the next
Periodic assessment is needed so that fluid may be adjusted accordingly

Clinical parameters should be monitored closely and correlated with the
hematocrit. This will ensure adequate hydration, avoiding under and over
hydration.

The IVF rate may be decreased anytime as necessary based on clinical
assessment.

If the patient shows signs of deterioration, see Management for compensated
or hypotensive shock, whichever is applicable.
Compensated shock (systolic pressure maintained but has signs of plasma leakage [hemoconcentration or reduced perfusion])
BOX A - Obtain baseline HCT. Fluid resuscitation with plain isotonic crystalloid 10-15ml/kg/hr over 1 hour. Give oxygen support
Improvement
BOX B - IV crystalliod 5-7ml/kg/hr for 1-2hours, then:
reduce to 3-5 ml/kg/hr for 2-4 hours;
reduce to 2-3 ml/kg/hr for 2-4 hours;
Fluids should not exceed 3 litres per day to avoid
fluid overload
If feasible, monitor HCT every 8-12 hours or as
necessary
Reassess hemodynamic status frequently
including urine output
Monitor for signs of bleeding
BOX C Administer 2
nd

bolus of fluid,
colloid/crystalloid
10-20ml/kg/hr in 1 hour
BOX D If there are signs
of occult/overt bleeding
initiate transfusion with
fresh whole blood 20ml/kg
or PRBC 10ml/kg.
Reassess hemodynamic
status and bleeding
parameters.
1. If improve go to
BOX B
2. If patient does
not improve, go to
BOX E
Patient is stable
HCT decreases
Patient is unstable
HCT increases
Go to BOX B Administer 3
rd
bolus of
fluid (colloid/crystalloid)
10-20ml/kg/hr for 1 hour
If patient improves,
go to BOX B
BOX E - If patient does not improve,
consider inotropes and refer
to tertiary center
YES NO
HCT or High HCT
Fluid management for patients admitted to the hospital with
DHF Grade III (Compensated Shock)
1. If patient is stable and HCT increases
by 10% from baseline, correlate
clinically and assess need to increase
fluid rate.
2. If patient is unstable and HCT
increases, go to BOX B
3. If patient is unstable and there is a
sudden drop in HCT, look for signs
of bleeding. Consider transfusion with
fresh whole blood 20ml/kg or PRBC 10ml/kg.
4. If patient is stable for 48 hours, stop
IVF or give maintenance fluids or ORS.
Hypotensive Shock
BOX A - Obtain baseline HCT. Fluid resuscitation with 20ml/kg plain isotonic crystalloid or colloid over 15 minutes. Give oxygen support
Improvement
BOX B Crystalloid/Colloid 10ml/kg/hr for 1hour,
then continue with:
5-7ml/kg/hr for 1-2 hours;
reduce to 3-5 ml/kg/hr for 2-4 hours;
reduce to 2-3 ml/kg/hr for 2-4 hours;
Fluids should not exceed 3 litres per day to avoid
fluid overload
If feasible, monitor HCT every 6 hours or as
necessary
Reassess hemodynamic status frequently
including urine output
Monitor for signs of bleeding
BOX C Administer 2
nd

bolus of fluid (colloid) 10-20ml/kg/hr
over to 1 hour. Check hemodynamic
parameters.
BOX D If there are signs
of occult/overt bleeding
initiate transfusion with
fresh whole blood 20ml/kg
or PRBC 10ml/kg.
Reassess hemodynamic
status and bleeding
parameters.
1. If improve go to
BOX B
2. If patient does
not improve, go to
BOX E
Patient is stable
HCT decreases
Patient is unstable
HCT increases
Reduce IVF rate
7-10ml/kg/hr for
1-2 hours
Administer 3
rd
bolus of
fluid (colloid/crystalloid)
10-20ml/kg/hr for 1 hour
If patient improves,
go to BOX B
BOX E - If patient does not improve,
consider inotropes and refer
to tertiary center
YES NO
HCT or High HCT
1. If patient is stable and HCT increases
by 10% from baseline, correlate
clinically and assess need to increase
fluid rate.
2. If patient is unstable and HCT
increases, go to BOX B
3. If patient is unstable and there is a
sudden drop in HCT, look for signs
of bleeding. Consider transfusion with
fresh whole blood 20ml/kg or PRBC 10ml/kg.
4. If patient is stable for 48 hours, stop
IVF or give maintenance fluids or ORS.
Fluid management for patients admitted to the hospital with
shock DHF Grade IV/DSS (Hypotensive Shock)
If patient remains stable,
go to BOX B
ANNOTATIONS:
a. If HCT is not readily available, assess hemodynamic status of patient using parameters in Table 5.
b. Assessment of improvement should be based on 7 parameters: mental status, heart rate, blood pressure,
respiratory rate, capillary refill time, peripheral blood volume, extremities
c. Crystalloids (Ringers lactate or 0.9 NaCl solutions) have been shown to be safe and as effective as colloid
solutions (dextran, starch, or gelatin) in reducing the recurrence of shock and mortality.
Crystalloids
0.9% saline [normal saline]/ NSS
Normal plasma chloride ranges from 95 to 105 mmol/L. 0.9% Saline is a suitable option for initial fluid
resuscitation, but repeated large
volumes of 0.9% saline may lead to hyperchloremic acidosis. Hyperchloremic acidosis may aggravate
or be confused with lactic acidosis from prolonged shock. Monitoring the chloride and lactate levels will
help to identify this problem. When serum chloride level exceeds the normal range, it is advisable to
change the other alternatives such as Ringers Lactate.
Ringers Lactate
Ringers Lactate has lower sodium (131mmol/L) and chloride (115mmol/L) contents and osmolality of
273mOsm/L. It may not be suitable for resuscitation of patients with severe hyponatremia. However, it is
a suitable solution after 0.9 Saline has been given and the serum chloride level has exceeded the normal
range. Ringers Lactate should probably be avoided in liver failure and patients taking metformin where
lactate metabolism may be impaired.
Colloids
The types of colloids are gelatin-based, dextran-based and starch-based solutions. One of the biggest
concerns regarding their use is their impact on coagulation.
Dextrans may bind to von Willebrand factor/Factor VIII complex and impair coagulation the most. However,
this was not observed to have clinical significance in fluid resuscitation in dengue shock. Dextran 40 can
potentially cause an osmotic renal injury in hypovolemic patients.
Gelatin has the least effect on coagulation among all the colloids but the highest risk of allergic reactions.
Allergic reactions such as fever, chills and rigors have also been observed in Dextran



Inotropes
The use of inotropes should be decided on carefully and it should be started after adequate fluid
volume has been administered.
To calculate the AMOUNT of Dopamine to be added to 100 ml of IV base solution:
mg of Dopamine = 6 X desired dose [mcg/kg/min] X weight[kg]
desired fluid rate [ml/hr]

To calculate the VOLUME of drug to be added to 100 ml of IV base solution:
Ml of Dopamine = mg of drug [determined using formula above]
concentration of drug (mg/ml)

Preparation of Dopamine: 40 mg/ml, 80 mg/ml
HEMODYNAMIC ASSESSMENT: CONTINUUM OF HEMODYNAMIC CHANGES
Parameters Stable Condition Compensated Shock Hypotensive Shock
Sensorium Clear and Lucid Clear and Lucid Change of mental status
(restless, iiritable)
CRT Brisk (<2sec) Prolonged (>2sec) Very prolonged mottled skin
Extremeties Warm and Pink Cool Peripheries Cold And Clammy
Peripheral Pulse Good volume Weak and Thread Feeble or absent
Heart rate Normal for Age Tachycardia Severe Tachycardia with
bradycardia in the late shock
Blood Pressure Normal for age
Normal pulse pressure for
age
Normal systolic pressure but
rising diastolic pressure.
Narrowing pulse pressure.
Postural hypotension
Narrowed pulse pressure
(<20mmHg) Hypotension,
unrecordable BP, Metabolic
Acidosis.
Respiratory Rate Normal for Age Tachypnea Hyperpnea, Kussmal
breathing
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