Cagayan State University

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

PEDIA WARD DECURY

Submitted by: (Year III Section Beta C1 – Group 3)

Demegillo, Ron Andrie V.
Bunuan, Kristine Xandra D.
Nikita

Submitted to: Romeo Calubaquib, M.D.

PATIENT’S PROFILE

Name (Initials) : B.T.

Age : 15y/o
Gender : Male
Address : Pamplona, Cagayan
Birth place : Pamplona, Cagayan
Birth date : February 20, 2003

Present Hospital of Admission : Cagayan Valley Medical Center

Date of Admission : November 13, 2018
Time of Admission : 5:00 PM
Number of Admission : 1

Date of Interview : November 16, 2018

Time of History Taking : 1:10 PM
Informant : Patient and his mother
Reliability 95%

Chief Complaint
- Abdominal pain and knees to feet pain

HEALTH HISTORY
History of Present Illness:

2 days prior to admission, the patient had a high grade fever, nausea, headache and
a generalized body pain. All of these persisted throughout the day. The mother gave him
paracetamol every 4 hours which haven’t alleviated the fever. A day prior to admission, the
patient had reached a temperature of 40.3 ͦC according to the mother. At evening of the
same day, the patient had vomited, generalized body pain and weakness.

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 On the day of the admission he had a much worse signs and symptoms. He was also
having a hard time walking as his pain in his feet was becoming unbearable which prompted
them to go to Cagayan Valley Medical Center.

Past Medical History

Childhood Illness:
• He was previously hospitalized twice because of dengue when he was 4 and the
other one when he was 10 years old but the mother and the patient can’t remember
the diagnosis.
Surgical:
• No history of surgery
Immunization:
• Completed vaccination under EPI
• BCG, Penta, OPV, Measles, MMR
Allergies:
• Allergy to eggs
Psychological
• No known psychological problem

Pregnancy and Birth History:

 The mother of patient BT carried him to full term with 3 prenatal check ups on their
barangay health center. Patient BT was born to a 31 year old mother at that time (2003)
G1T1P0A0L1 in their health center via vaginal canal with the aid of local midwife.
According to her, vaccine was given to the baby on the same day. His mother cannot
remember the exact birth weight but it is within normal range according to the midwife.

Nutritional History:
 The patient had mixed feeding since birth as the mother had insufficient breast milk.
The mother stopped giving him breast milk when he was 2 years old.
 Complementary feeding was started at 6 month with mash vegetables and rice
 His usual food are mostly vegetables (dinengdeng), pork and fish.

Family History:
 His siblings have asthma.
 His father is a known hypertensive and has maintenance medications.
 Other family members have no known illnesses.
Personal and Social History:
 Patient BT is the 1st child among 3 siblings.
 Patient BT is a nonsmoker and non-alcohol drinker
 His father is 53y/o farmer and his mother is 46y/o housewife
 Their source of water for drinking are the ones being bought in water refilling stations.
 Their main source of income is farming
 Their house has 2 floors which is located near the main road in a crowded
neighborhood and is made of concrete.

REVIEW OF SYSTEMS
General:

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 • Weight loss, fever
Integuments:
• No rashes, lumps, itching, dryness, color change, and changes in nails
HEENT:
• Head – cluster headache, no neck pain
• Eyes – periorbital pain, no changes in visual field, and blurring.
• Ears – (+)dizziness, no changes in hearing, no pain
• Nose – no nasal discharge and congestion
• Throat – difficulty in swallowing, presence of ulceration and bleeding, no hoarseness
Respiratory:
• (+) Chest pain
• No cough and dyspnea
Cardiovascular:
• (+) chest pain
• No shortness of breath
Gastrointestinal:
• (+) Dysphagia
• Abdominal Pain
Genitourinary:
• No difficulty and pain in urinating
Endocrine:
 Loss of appetite
Hematologic:
 (+) gumbleeding
Musculoskeletal:
• Difficulty moving
• Muscle weakness and pain on both extremities
• Joint Pain
Psychiatric:
• Exhausted mood
PHYSICAL EXAM

General Survey:
 Patient BT is in a supine position awake, conscious, coherent and cooperative.
 He was hooked to an IV lactated ringer’s solution on his right arm.
Vital Signs:
 BP: 125/80 mmhg
 HR: 88 bpm
 RR:
 Temp: 38.6 Co

Integumentary:
 Moderate perspiration, moist skin
 Brown in complexion
 No pallor and jaundice Warm to touch
 Good skin turgor (1sec.)

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 Head and Neck
 Hair is evenly distributed, no gray hair
 Facial features are symmetrical
 No enlarged nodes or mass palpated
Eyes:
 Pink conjunctiva
 Coordinated eye movement
 Anicteric sclera
Ears:
 No swelling, redness and discharge obseved
Nose:
 Both nares are patent and non tender
 No rhinorrhea
Mouth and throat:
 Lip are dry and yellowish teeth
 Bleeding oral mucosa (gums and lips)
Chest and Lungs:
 Normal and symmetrical lung expansion
 No wheezes and rales
Heart:
 Regular rate and rhythm, no murmur
 PMI is at the 5th intercostal space midclavicular line
 No thrills, click and gallops
Gastrointestinal:
 Flat, normoactive bowel sound
Peripheral Vascular:
 No gross deformity
 No edema
Neurologic
 No complaint of memory loss, seizure, paralysis, paresthesia and tremor
Hematologic:
 (+) mucosal bleeding

INITIAL IMPRESSION:

 Leptospirosis

DIFFERENTIAL DIAGNOSES:
1. A
2. B
3. C

Rule In Rule Out

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 PLAN OF CARE:

Diagnostic Tool Description

MANAGEMENT:

Non-Surgical Surgical

CASE DISCUSSION:
DENGUE FEVER – (HEMORRHAGIC?)

CASE DISCUSSION:
Dengue : Dengue is a mosquito-borne viral disease that has rapidly spread in all
regions of WHO in recent years. Dengue virus is transmitted by female mosquitoes mainly of
the species Aedes aegypti. Symptoms typically begin three to fourteen days after infection. This
may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic skin
rash. Recovery generally takes two to seven days. In a small proportion of cases, the disease
develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding, low levels
of blood platelets and blood plasma leakage, or into dengue shock syndrome, where
dangerously low blood pressure occurs. There are 4 distinct, but closely related, serotypes of
the virus that cause dengue (DEN-1, DEN-2, DEN-3 and DEN-4).

CLINICAL MANIFESTATION
Case Definition for Dengue
Individual presenting with high grade fever for at least 2 days
Working in farm lands as a high risk exposure
Presented with at least two of the followings
 Headache
 Muscle, bone and joint pain
 Nausea
 Vomiting

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  Pain behind the eyes
 Swollen glands
 Rash

Most people recover within a week or so. In some cases, symptoms worsen and can become life-
threatening. Blood vessels often become damaged and leaky. And the number of clot-forming
cells (platelets) in your bloodstream drops. This can cause a severe form of dengue fever, called
dengue hemorrhagic fever, severe dengue or dengue shock syndrome.

Severity of dengue
Dengue hemorrhagic fever or severe dengue include:
 Severe abdominal pain
 Persistent vomiting
 Bleeding from your gums or nose
 Blood in your urine, stools or vomit
 Bleeding under the skin, which might look like bruising
 Difficult or rapid breathing
 Cold or clammy skin (shock)
 Fatigue
 Irritability or restlessness

Phases of Dengue Hemorrhagic Fever

1. The Febrile Phase: Early in the course of illness, patients with DHF can present much like
DF, but they may also have hepatomegaly without jaundice (later in the Febrile Phase).
Less commonly, epistaxis, bleeding of the gums, or frank gastrointestinal bleeding occur
while the patient is still febrile.

2. The Critical (Plasma Leak) Phase: About the time when the fever abates, the patient enters
a period of highest risk for developing the severe manifestations of plasma leak and
hemorrhage. If left untreated, this can lead to intravascular volume depletion and
cardiovascular compromise.

3. The Convalescent (Reabsorption) Phase: The third phase begins when the Critical Phase
ends and is characterized when plasma leak stops and reabsorption begins. During this
phase, fluids that leaked from the intravascular space (i.e., plasma and administered
intravenous fluids) during the Critical Phase are reabsorbed.

DIAGNOSIS
Basic laboratory work up
 CBC
 Renal & liver function test
 Bleeding parameters
 ABG
 Urinalysis

Detection method for dengue

 Virus isolation
 RT-PCR
 NS1 Antigen Capture

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  IgM-IgG seroconversion and detection

MANAGEMENT OR MEDICATIONS:
No specific treatment for dengue fever exists. It is advised to drink plenty of fluids to avoid
dehydration from vomiting and a high fever.

Medications : Acetaminophen (Tylenol, others) can alleviate pain and reduce fever.
Avoid pain relievers that can increase bleeding complications — such as aspirin, ibuprofen and
naproxen sodium.

Supportive care in a hospital

 Crystalloids: 0.9% Sodium Chloride or Lactated Ringer's to be given by Intravenous (IV)
route for fuild and electrolyte replacement
 Volume expanders: Dextran 40 is given to increase and restore the intravascular volume,
tissue perfusion as a Tx for hemorrhagic shock.
 Blood pressure monitoring
 Transfusion to replace blood loss