PEDIATRIC CASE

PRESENTATION
KARNAN HEMA
KALLATHIYAN PATTABIRAMAN
 OBJECTIVES

❖ To present a comprehensive history and physical

examination
❖ To arrive at a logical impression and differential
diagnosis
❖ Diagnostics
❖ Management plans
❖ Case discussion
 GENERAL DATA
• PATIENT NAME: C.J
• AGE:16 Y.O.
• SEX:MALE
• DOB:10/30/2003
• RELIGION:CATHOLIC
• CIVIL STATUS:SINGLE
• ADDRESS: BARANGAY 6-A DAVAO CITY
• INFORMANT:MOTHER
• DATE OF ADMISSION:15-FEB- 2020
• DATE OF INTERVIEW:15-FEB-2020
• RELIABILITY:90 %
CHIEF COMPLAINT

FEVER
 UNDOCUMENTED FEVER
SELF MEDICATED WITH BIOFLU
PARACETAMOL
3 DAYS PTA TEMP RELIEF
2 EPISODES OF VOMITING(1/2 CUP)
NON BLOODY,
LOWER EXTREMITY PAIN ,
CONSULT MADE
CBC DONE PLATELET 290
PARACETAMOL AND CALCIUM
TABLET WAS GIVEN
 STILL WITH INTERMITTENT FEVER
LOWER EXTREMITY PAIN
2DAYS PTA GIVEN PARACETAMOL
W/TEMPORARY RELIEF
NO CONSULT
 STILL WITH ABOVE SYMPTOMS

ON THE DAY OF CONSULT AT PRIVATE CLINIC

CBC DONE WITH PLATELET OF197
ADMISSION NO RELEIF PROMPTED
CONSULTED AT ER
PAST MEDICAL HISTORY

! (-)PRIOR SURGERY
! (-)ALLERGIES
! (+)CHICKEN POX 2017
 FAMILY HISTORY

❖ (-)asthma
❖ (-)hypertension
❖ (-)cancer
❖ (-)diabetes
❖ (-) Heart disease
 BIRTH HISTORY
1. TERM BABY BOY BORN TO A G3P2 42 YEAR OLD
MOTHER VIA C SECTION WITH GOOD CRY AND
PINK ALL OVER AS CLAIMED BY MOTHER.
 PRENATAL HISTORY
• MOTHER HAD REGULAR PRENATAL CHECKUP AND HAD IRON
AND CALCIUM SUPPLEMENTS AND DID NOT SMOKE OR DRINK
ALCOHOL AS CLAIMED BY MOTHER
 NEONATAL COURSE
FEEDING HISTORY
BREAST FEEDING: EXCLUSIVE FOR 6MONTHS
COMPLEMENTARY FEEDING STARTS AT 7
MONTHS
NOW EATS RICE MEAT
DEVELOPMENTAL HISTORY

GROSS MOTOR:STARTED TO WALK BY 1 year

FINE MOTOR : SCRIBBLE BY 18 MONTHS
LANGUAGE : MAMA DADA 1 YEAR
TOILET TRANING :3YEARS
SCHOOL :4YEARS
GROWTH CHART

BMI 16.
for age)
GROWTH CHART
 IMMUNIZATION

❖ As claimed complete immunization at the health centre.

PERSONAL AND SOCIAL
The patient is staying with his parent
Parents are non smokers
Parents are non alcoholic
ENVIRONMENTAL HISTORY

❖ Patient lives in a clean surrounding

❖ They consume mineral water
❖ Reported cases of dengue in the neighborhood
❖ Nobody in the family was sick.
 REVIEW OF SYSTEM
GENERAL: (-)WEAKNESS
SKIN: (+)RASHES,(-)ITCHINESS,(-)DISCOLORATION
EYES: (-)VISUAL DYSFUNCTION,(-)PAIN,(-)DISCHARGE,
(-)REDNESS
EARS: (-)DEAFNESS,(-)DISCHARGE
NOSE: (-)SINUSITIS,(-)ANOSMIA
MOUTH AND THROAT: (-)SORENESS (-) HOARSNESS
RESPIRATORY: (-)PAIN,(-)HEMOPTYSIS
CARDIAC: (-)CHEST PAIN,(-)NOCTURNAL DYSPNEA
GI: (-)NAUSEA,(-)CHANGE IN BOWEL HABIT
 REVIEW OF SYSTEM
GENITO URINARY: (-)DYSURIA,(-)FLANK PAIN,(-)URINE FREQUENCY
NEUROLOGICAL: (+)HEADACHE,(-)SEIZURE,(-)WEAKNESS
MUSCULOSKELETAL: (-)SWELLING,(-)WASTING
HEMATOPOITIC: (-)BLEEDING,(-)PALLOR
 PHYSICAL EXAMINATION

AWAKE, ALERT, CONSCIOUS AND NOT IN RESPIRATORY DISTRESS

VITAL SIGNS
uBLOOD PRESSURE: 100/768mmHg
uRESPIRATORY RATE:20CPM
uCARDIAC RATE:103 BPM
uTEMPERATURE: 36.8 C

ANTHROPOMETRIC MEASURES:
WEIGHT- 43 Kg
HEIGHT- 163cm
BMI- 16.2
 PHYSICAL EXAMINATION
HEENT
H: ATRAUMATIC, NORMOCEPLHALIC, NO LESIONS NO MASSES
E: ANICTERIC SCLERAE, PINK PALPEBRAL CONJUNCTIVA, PUPILS
NORMOREACTIVE TO LIGHT, NO DISCHARGE ,PERIORBITAL RASH
E: NO DISCHARGE, NO LESIONS, NO TENDERNESS NOTED OVER THE TRAGUS
AND MASTOID PROCESS
N: NO DISCHARGE 
T: MOIST LIPS AND BUCCAL MOCOSA, UVULA MIDLINE, NO DEVIATION OF
THE TONGUE NOTED, NO INFLAMMED TONSILS, TRACHEA MID LINE
 PHYSICAL EXAMINATION
CHEST AND LUNGS
I: EQUAL CHEST EXPANSION, NO RETRACTIONS ,RASH WAS NOTED
P: SYMMETRICAL TACTILE FREMITUS, NO TENDERNESS
P: RESONANT NOTES HEARD OVER BOTH LUNG FIELDS
A: CLEAR BREATH SOUND, NO CRACKLES, NO WHEEZING
CVS:
I:ADYNAMIC PRECORDIUM
P:NO HEAVES AND THRILL,PMI AT 5 TH  ICS  IN LEFT MIDCLAVICULAR LINE
A:DISTINCT HEART SOUND,NO MURMUR NOTED,REGULAR RHYTHM
     
 PHYSICAL EXAMINATION
ABDOMEN:I: NON DISTENDED,NO SCARS
                          A:NORMOACTIVE BOWEL SOUND
                          P:DULLNESS ON RUQ, TYMPANIC SOUND HEARD IN ALL
OTHER QUADRANTS
                          P:NO MASSES,TENDERNESS ON PALPATION LEFT
UPPERQUADRANT AND EPIGASRTIC
EXTREMETIES:
CRT <2 SEC,FULL PULSE, WARM EXTREMITIES,(-)EDEMA
 PHYSICAL EXAMINATION
uNEUROLOICAL EXAMINATION:
CN1: CAN SMELL COFFEE
 CN2: INTACT,PUPIL RESPONSE TO LIGHT
 CN3,4,6: INTACT EXTRA OCULAR MOMENT
 CN 5: INTACT FACIAL SENSATION
 CN 7: NO FACIAL ASYMMETRY,ABLE TO SMILE AND FROWN
CN 8: HEARING INTACT
CN 9,10: INTACT GAG REFLEX
CN 11: ABLE TO LIFT SHOULDER AND TURN HEAD AGAINST RESISTANCE
CN12: SYMMETRIC TONGUE MOVEMENT,NO DEVIATION AND ABLE TO SWALLOW 
                     
 HEADSSS
• HOME
• PATIENT LIVES WITH PARENTS AND SIBLINGS.
• GOOD AND FRIENDLY RELATIONSHIP WITH SIBLINGS.
• EDUCATION
• CURRENTLY IN 11GRADE
• PERFORMING GOOD IN SCHOOL
• ACTIVITIES
• PLAYS BASKET BALL WITH FRIENDS
• DRUGS
• DOES NOT SMOKE OR DRINKS ALCOHOL
• SEXUAL ACTIVITIES
• NOT ACTIVE
• SUICIDE
• NO THOGHTS OF SUICIDE
• NOT DEPRESSED
• SAFETY
• NOT HIGH RISK
 BLOOD PRESSURE
DATE 16 FEB 17 FEB 18 FEB 19 FEB 20 FEB 21 FEB
2020 2020 2020 2020 2020 2020
TIME

4 AM 90/60 100/72 90/60 100/60 100/80

8 AM 90/60 100/60 90/60 90/70

12 PM 90/70 100/60 90/60 90/70

4 PM 100/60 90/60 90/62 90/70

8 PM 100/72 100/60 90/60 90/70

12 AM 100/70 90/60 90/60 100/70

 TEMPERATURE
DATE 16 FEB 17 FEB 18 FEB 19 FEB 20 FEB 21 FEB
2020 2020 2020 2020 2020 2020
TIME

4 AM 36.6℃ 38.8℃ 36℃ 36℃ 36

8 AM 36.6℃ 37.8℃ 36.4℃ 35

12 PM 36.8℃ 37.2℃ 36.4℃ 35

4 PM 38.6℃ 36℃ 36.2℃ 36

8 PM 38.2℃ 37.4℃ 36.4℃ 35

12 AM 38.8℃ 36.2 ℃ 36℃ 35

 SALIENT FEATURES

❖ 16 YEAR OLD, MALE

❖ INTERMITTENT FEVER
❖ LIVES IN A DENGUE ENDEMIC AREA
❖ ABDOMINAL PAIN
❖ EXTREMITY PAIN
 IMPRESSION

❖ DENGUE WITH WARNING SIGN

DIFFERENTIAL DIAGNOSIS
 MALARIA
RULE IN RULE OUT

NO TRAVEL HISTORY TO ENDEMIC

FEVER
PLACES

HEADACHE
(-) DIAPHORESIS

ABDOMINAL PAIN (-) ANEMIA

 TYPHOID FEVER
RULE IN RULE OUT

FEVER (-) DIARRHEA

HEADACHE (-)ANOREXIA

ABDOMINAL PAIN
(-) ROSE SPOTS APPEAR
 CHIKUNGUNYA
RULE IN RULE OUT

FEVER (-) ARTHALGIA

HEADACHE (-) BODY MALAISE

THROMBOCYTOPENIA (-) CONJUNCTIVITIS

LEUKOPENIA (-) NAUSEA

NO TRAVEL HISTORY TO ENDEMIC

PLACES

(-) MACULOPAPULAR RASH

 DENGUE
RULE IN RULE OUT

INTERMITTENT FEVER

HEADACHE
THROMBOCYTOPENIA

ABDOMINAL PAIN

LIVES IN DENGUE ENDEMIC AREA

 CBC REPORT

TIME HGB HCT RBC WBC PLT

16 feb
138 0.40 5.29 2.76L 149L
2:30am

8:40 am 139 0.41 5.37 3.25 109L

9.30 PM 131 L 0.38 L 5.06 2.52L 66 L

17 feb
138 L 0.39 L 5.25 2.35 L 37 L
4:40am
 CALCIUM
❖ 1.91L 2.23-2.58
 CBC REPORT

TIME HGB HCT RBC WBC PLT

17 FEB
137 0.40 14 L
8.24PM

18 FEB
146 0.41 12 L
4.42 AM

1.43 PM 136 0.39 14L

 CBC REPORT

TIME HGB HCT RBC WBC PLT

18 FEB
136 0.40 5.29 4.11 18L
9.25PM

19 FEB
135 0.40 5.24 4.35L 41L
1:32PM

9:27 PM 130 0.38 5.05 4.70 62L

20FEB 135 0.40 5.30 5.43 74L

 DATE INTAKE URINE OUTPUT BALANCE

02/16/2020 3250 2578 675

02/17/2020 3950 2008 1942

02/18/2020 5900 4800 1100

 DATE INTAKE URINE OUTPUT BALANCE

02/19/2020

02/20/2020
CASE DISCUSSION
 DENGUE FEVER

ETIOLOGY Genus: Flavivirus

ssRNA virus (4 Serotype)

VECTOR : A.Aegypti

INCUBATION PERIOD : 4-10

DAYS
PATHOPHYSIOLODY
REPLICATION OF VIRUS
 THE PHASES OF DENGUE

The course of infection is divided into three phases

1.febrile phase

2.critical phase

3.recovery phase
 FEBRILE PHASE (2 -7 DAYS )
•High-fever over 40’c(104’F), biphasic in nature
• generalized pain.
• headache, usually lasts two to seven days.
• rash occurs in the first or second day of symptoms as flushed
skin or later in the course of illness(days 4-7),as a measles-like
rash.
• some petechiae can appear at this point
• mild bleeding from the mucous membrane of the mouth and
nose.
 CRITICAL PHASE (24-48 DAYS )

•During this phase there may be significant fluid accumulation in the chest and
abdominal cavity due to increased capillary permeability and leakage.
• This leads to depletion of fluid from the circulation and decreased blood
supply to vital organs.
•organ dysfunction and severe bleeding, typically from the gastrointestinal
tract .
• Shock(dengue shock syndrome) and hemorrhage(dengue hemorrhagic fever)
occur in less than 5% of all cases of dengue.
• However those who previously been infected with other serotypes of dengue
fever(secondary infection) are at an increased risk.
RECOVERY PHASE(48-72) DAYS

• Resorption of the leaked fluid into the bloodstream.

• This usually lasts two to three days.
• severe Pruritus and a slow heart rate.
• During this stage, a fluid overloaded state may occur.
• It affects the brain, it may cause a reduced level of
consciousness or seizures.
 DISCHARGE CRITERIA
Clinical

No fever for 48 hrs

Improvement in clinical status (general well being, appetite, hemodynamic status, no respira

Laboratory

Increasing trend of platelet count.

Stable hematocrit without intravenous fluids.

 PREVENTION
❖ Anti-mosquito measures

❖ Avoid open stagnant water in and around home

❖ Bed nets

❖ Long sleeved clothing

❖ In house spraying

❖ Mosquito repellents
 DENGVAXIA

❖ use of anti-dengue vaccine Dengvaxia in the Philippines.

❖ In late November 2017 the Philippine Department of Health (DOH)
suspended a school-based vaccination program utilizing French drug-based
vaccine maker Sanofi Pasteur's Dengvaxia vaccine.
❖ Reports circulated that several children died from various complications
allegedly attributed to the dengue vaccine.
❖ Shortly after, the company made a statement that its product poses higher
risks to people without prior dengue infection.
❖ As of August 2019, over 600 people who have received the vaccine, mostly
children, have died (though not necessarily caused by the vaccine itself) and
the DOH has banned the vaccine's sale or use in the country.
THANK YOU