Transcript A Case of N.E. 16 y.o Male cc: fever x 3 days

A Case of N.E.
16 y.o Male
cc: fever x 3 days
History of Present Illness
 3 days PTC:
 (+) fever with chills
(Tmax 39.5ºC)
(+) headache
(+) generalized
weakness
(+) myalgia
(+) sore throat
(+) cough with
productive sputum
(whitish)
(-) epistaxis
(-) gum & aural bleeding
(-) hematemesis
(-) hematuria
(-) hematochezia
(-) melena
(-) petechiae/ ecchymoses/
rash
Px has a neighbor
diagnosed with Dengue
History of Present Illness
 3 days PTC:
 (+) fever with chills
(Tmax 39.5ºC)
(+) headache
(+) generalized
weakness
(+) myalgia
(+) sore throat
(+) cough with
productive sputum
(whitish)
•
•
•
•
•
(-) calf pain
(-) abdominal pains
(-) jaundice
(+) good urine output
(-) hx of wading through
the floodwaters
History of Present Illness
 3 days PTC:
 (+) fever with chills
(Tmax 39.5ºC)
(+) headache
(+) generalized
weakness
(+) myalgia
(+) sore throat
(+) cough with
productive sputum
(whitish)
Medications taken:
Paracetamol 500mg/tab
every 4 hours for fever
with minimal relief
Review of Systems
(-) dizziness
(-) difficulty of breathing
(-) chest pains
(-) palpitations
(-) weight loss >20%
(-) decrease in appetite
Past Medical History
 (-) hypertension, diabetes, liver, lung and
kidney disease
 (-) asthma, allergies to food and drugs
 (-) previous hospitalizations and surgeries
Birth and Maternal History
 Pt was born FT at Fabella hospital by an
OB-Gyne via SVD to a then G1P0 mother.
(-) maternal illness, exposure to
chemicals, radiation
(-) exposure to measles and varicella
infection
Immunization History
 completed the EPI c/o LHC
(+) MMR c/o private pediatrician
Nutritional History
Px was fed with both breastmilk and
formula since birth.
The patient’s current diet consists of rice,
meat, fish, poultry, with minimal fruits and
vegetables
Personal and Social History
 H - good rel’p with parents & siblings
 E - 2nd year HS, satisfactory performance, (-)
failing grades
 A - basketball, computer games
 D - no use of illicit drugs
 S - has groups of friends in school and
neighborhood
 S - not sexually active
 S - no suicidal thoughts
Personal and Social History
Non-smoker, occasional alcoholic
beverage intake
Px lives with his mother and 2 other
siblings at home in Pasay City
Mother is the breadwinner of the family
and works in a factory
Px’s family gets monthly stipend from
relatives who work abroad
HPN
Asthma
Genogram
9
7
32
CVD
PTB
30
27
24
16
Physical Examination
 BP 90/60 HR 120s RR 20 T 38.6
 Px is awake, coherent, oriented, weak-looking
 Pinkish conjunctivae, anicteric sclerae, (+) pharyngeal
injection, (-) cervical lymphadenopathies, (-) anterior
neck masses, (-) nasoaural bleeding, (-) gum bleeidng
 Equal chest expansion, clear breath sounds, (-)
wheezes, (-) crackles, (-) retractions
 Adynamic precordium, distinct heart sounds,
tachycardic, regular rhythm, no murmurs
 Soft and flat abdomen, normoactive bowel sounds, (-)
masses/ tenderness, liver and spleen nonpalpable
 Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-)
clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses,
(-) calf tenderness, (+) flushed skin
Tourniquet Test
 negative (<20 spots in 1 square inch)
Assessment
 R/O Dengue Fever/ Dengue Hemorrhagic Fever
Plan
For CBC with platelet count
Paracetamol 500mg/tab 1 tab every 4
hours for fever
Tepid sponge bath
Supportive therapy
Increase oral fluid intake
Avoid dark colored foods
WOF bleeding episodes
Questions Questions…..
 What if the CBC was normal? It has only been a
3 day Hx of fever..
 A negative tourniquet test doesn’t necessarily r/o
DF/DHF.. What now?
 Its too early to say.. What can we do at this
point? Is watchful waiting enough to prevent the
complications of DF/DHF?
 Recent dengue cases are noted to be more
virulent than the past (cross-immunities etc)
DF/DHF Epidemiology
10,383 cases of DF/DHF noted by Nat’l
Epidemiological Center of DOH (Jan-June
20)
104 deaths (case fatality of 1%)
Most cases were at NCR, Region 4A, 5,6
Most deaths are caused by complications
secondary to DHF and DSS
Most are diagnosed LATE
Bio-Rad Dengue NS1 Antigen Test
New offer at PGH Central Lab!!
Used in private hospitals since 2007
serum
 available in minutes
May detect 4 dengue serotypes in the first
5 days of viremia (febrile phase)
Diagnostic Dilemma
P - pediatric patients with clinical signs of
Dengue Fever, in the first 3 days of fever
I - Dengue NS1Antigen test
C - virus isolation test
O - sensitivity and specificity in diagnosis
of Dengue Fever
M - cross sectional study
Clinical Question (Diagnostics)
 What is the sensitivity and specificity of
Dengue NS1Antigen test versus a viral
isolation test in the diagnosis of DF/DHF in
pediatric patients with clinical signs of DF
in the first 3 days of viremia in a cross
sectional study?
Therapeutic Dilemma
P - Pediatric patients with clinical signs of
systemic viral infection (SVI)
I - Immunologicals
C - placebo
O - shortening the course of the disease
M - RCTs
Clinical Question (Therapeutics)
 In pediatric patients with clinical signs of
systemic viral infection, is there a
significant difference in giving
immunologicals versus placebo in
shortening the course of fever seen in
randomized controlled trials?