General Data:

A case of a 20-year-old/ Female student

Chief Complaint:
Fever
History of Present illness:

Onset 5th Day PTA On the day of admission

 Intermittent moderate-  Low to moderate grade  Rapid breathing
high grade fever intermittent fever
 Generalized headache  Poor appetite
 Myalgia  Vomiting of 4-6x a day at
 Arthralgia 100cc per bout
 Runny nose  Abdominal pain
 Sore throat  Severe myalgia
 Diagnosed with URTI and  Loose stool 2x
Conjunctivitis  Passed dark colored-urine
few times

Physical Examination:

VITAL SIGNS
Temperature 37.8°C Febrile
Blood Pressure 100/85mmHg Normal
Heart Rate 120bpm Tachycardia
Respiratory rate 28cpm Tachypnea
O2 Saturation 95% Normal
Weight 35kg Underweight

HEENT: generalized headache, runny nose, sore throat, erythematous conjunctivitis, dry and
cracked lips, icteric sclera
Chest and Lungs: Symmetrical chest expansion, no wheeze but with notable decreased breath
sounds, vocal and tactile fremitus mid to basal right lung field.
Abdomen: Abdominal pain, epigastric tenderness, hepatomegaly, negative for murphy’s sign,
no guarding nor rebound tenderness
Extremities: Pulses are poor, with cold and clammy extremities, capillary refill time >3 secs, no
bleeding nor rashes noted.
Salient Features:

Demographic profile HPI Physical Findings

 20 year-old female  Fever  Increased HR
 Generalized headache  Increased RR
 Myalgia  Flushed
 Arthralgia  Dry and Cracked lips but
 Runny nose ambulatory
 Sore throat (related to  Icteric sclera
dengue??)  Decreased breath sound,
 Erythematous Conjunctiva vocal and tactile fremitus
(is it connected to dengue? mid to basal right lung
Retroorbital pain?)
field (Pleural effusion?)
 Poor appetite
 Epigastric tenderness
 Vomiting
 Hepatomegaly
 Abdominal pain
 Poor pulses
 Loose stool
 Cold and clammy
 Dark-colored urine (could it
be due to dehydration?)
extremities
 Capillary refill time >3
secs

Primary Clinical Impression:

DENGUE FEVER WITH WARNING SIGNS (with pleural effusion)??
SEVERE DENGUE
Pathophysiology
Basis: Demographic Profile, Clinical Manifestations, Physical Findings
Possible Differentials:
- Malaria
- Typhoid fever
- Yellow fever
- Influenza
- Borreliosis
- Zika virus infection
- COVID-19
DENGUE FEVER

RULE IN RULE OUT

 Fever  Maculopapular rash
 Headache  Lymphadenopathy
 Severe myalgia  Shock and bleeding
 Arthralgia
 Poor appetite/ anorexia
 Flushed / flushing
 Persistent vomiting
 Abdominal pain
 Fluid accumulation
Warning signs
(pleural effusion)
 Hepatomegaly

(Source: Dravz trans/Harrison’s)

- Arthropod-borne infection (Aedes aegypti)
- Flaviviridae; Dengue virus serotypes 1-4
- Tropics and subtropics
o Large areas of the world have become vulnerable to the introduction of dengue
viruses, particularly through air travel by infected humans, and both dengue
fever and the related dengue HF are becoming increasingly common.
- A. aegypti: efficient vector of the yellow fever and chikungunya viruses, typically breeds
near human habitation using relatively fresh water; inhabits dwelling; bites during the
day.
- Febrile phase
 Patient has high grade fever
 Potential clinical issue is dehydration.
 Early organ impairment can also occur with dehydration particularly acute kidney
failure if the patient is an elderly with pre-existing diseases such as DM or
hypertension
 Platelet is high, haematocrit is very low
 IgM and IgG cannot yet be detected so dengue rapid test, only NS1 antigen will test
positive
- Critical phase
 No fever
 Potential clinical issue is shock and bleeding, as well as organ impairment
  Hematocrit increase and platelet decrease
 Naghehematoconcentrate na sya in response to bleeding and possible vasculitis?
- Recovery phase
 Temperature is normal
 Reabsorption of fluid and fluid overload. You should already decrease the IV fluid rate
 Platelet is rising and haematocrit goes back to normal
- Dengue fever is bimodal so sometimes patient will develop transient fever in the
recovery phase. After the 2nd wave of fever, patient already have complete recovery.

Clinical Manifestations
• Incubation period of 2-7 days, sudden onset of fever, headache, retroorbital pain, and back
pain along with the severe myalgia “break-bone fever”
• Macular rash on the first day as well as adenopathy, palatal vesicles, and scleral injection
• Near the time of defervescence – a maculopapular rash beginning on the trunk and spreading
to the extremities and the face
• Warning signs that may occur at or after defervescence (The presence of one or more of these
signs indicates the need for immediate medical evaluation):
o Abdominal pain or tenderness
o Persistent vomiting
o Mucosal bleeding
o Clinical fluid accumulation (i.e., pleural effusion or ascites)
o Increases in hematocrit concurrent with rapid decrease in platelet
o Liver enlargement (≥2)
o Lethargy or restlessness
• Epistaxis and scattered petechiae are often noted in uncomplicated dengue, and pre-existing
gastrointestinal lesions may bleed during the acute illness

Laboratory Findings
• Leukopenia, thrombocytopenia
• Elevated serum aminotransferase
• The diagnosis is made by IgM ELISA or paired serology during recovery or by antigen-detection
ELISA or RT-PCR during the acute phase
• Virus is readily isolated from blood in the acute phase if mosquito inoculation or mosquito cell
culture is used

-end of trans-
(Source: Harrison’s)

 rash in 50% of cases; initially diffuse flushing; midway through illness, onset of maculopapular
rash, which begins on trunk and spreads centrifugally to extremities and face; pruritus,
hyperesthesia in some cases; after defervescence, petechiae on extremities may occur.
-end of harrisons-
 Basis and Info for Pleural Effusion

How to diagnose Pleural effusion? Distinguish exudate and transudate?

What other pulmo diseases can you think of with the Chest PE?
(DOH)

REVISED DENGUE CASE CLASSIFICATION (DOH)

General Guidelines
Dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that includes
severe and non-severe forms of clinical manifestations. After the incubation period, the illness
begins abruptly and will be followed by 3 phases: febrile, critical, and recovery phase.
Febrile Phase
PRIMARY CLINICAL IMPRESSION

DIAGNOSTICS
PROGNOSIS

PREVENTION
 SEVERE DENGUE
+ PLASMA LEAKAGE: (+) SHOCK, (+) FLUID ACCUMULATION WITH RESPIRATORY DISTRESS
SHOCK:

Px is in Compensated shock due to the presenting signs and symptoms, which are cold and
clammy extremities, poor pulses, delayed capillary refill, and tachycardia.
MALARIA

R/I R/O
fever, headache, myalgia (1st 3days) (-) Conjunctivitis
abdominal pain (-) URTI
- The first symptoms of malaria are (-) arthralgia
non-specific; the lack of a sense of (-) pleural effusion
well-being, headache, fatigue, - Adults with severe falciparum malaria
abdominal discomfort, and muscle may develop noncardiogenic
aches followed by fever pulmonary edema even after several
persistent vomiting days of antimalarial therapy
- Nausea, vomiting, and orthostatic (-) severe myalgia (on the 5th day)
hypotension are common - While myalgia may be prominent, it is
Icteric sclera not usually as severe as in dengue
- Mild jaundice is common among fever,
adults
hepatomegaly
- Slight enlargement of the liver is also
common, particularly among young
children.
Epigastric tenderness
- … splenic enlargement is found in a
high proportion of otherwise healthy
individuals in malaria-endemic areas…
Capillary refill time >3 secs

To consider for Respiratory distress

But according to BATES’

Basis for rule out, Px has signs of pleural effusion not pulmonary edema which is seen in
Malaria.
R/I R/O
RR= 28cpm/ rapid breathing Chills and sweat

(https://www.cdc.gov/malaria/about/disease.html)

(https://www.cdc.gov/malaria/about/disease.html)
Poor appetite

https://sites.duke.edu/malaria/1-introduction-ddt-and-
malaria/malaria/malaria-symptoms/
HR: 120bpm, Poor pulses and cold and clammy extremities (-) Hypotension
Patient’s BP= 100/85

https://www.cdc.gov/malaria/about/disease.html

IM platinum
Increased heart rate, poor pulses and cold and clammy
extremities are manifested in hypotension/ shock
arthralgia

https://www.parashospitals.com/blogs/can-malaria-cause-
joint-pain/
 Diagnostic tools to differentiate malaria from dengue

1. Thin and thick blood smear: (+) presence of malarial parasite

(-) in dengue fever

2. Dengue IgM and IgG (ELISA): (-) malaria

(+) dengue fever

IgM antibody: usually detected by day five of illness

IgG antibody: detects past dengue infection

3. NS1 Antigen (Rapid) Test: (-) malaria

(+) dengue fever

TYPHOID FEVER

RULE IN RULE OUT

 Abdominal pain  Diarrhea
 Headache  Splenomegaly
 Myalgia  Erythematous macules and
 Arthralgia papules (rose spots)
 Anorexia  Prolonged fever
 Hepatomegaly  Chills
 Persistent vomiting  Cough
 Abdominal tenderness  Sweating
 Weak, rapid pulse  Malaise
 Cold and clammy skin  Diarrhea
 Severe dehydration?? Physical findings:
 Coated tongue
 Splenomegaly
 Rose spots
  Epistaxis
 Bradycardia

D
INFLUENZA

RULE IN RULE OUT

 Conjunctivitis  Rhinorrhea
 Sore throat  Persistent cough
 Fever  Malaise
 Myalgia  Fatigue
 Headache  Sweating
 Diffuse pharyngeal erythema
 Non-localizing scattered rales
 Rhonchi
 Wheezes
 Muscle pain elicited by pressure in
the calves and thighs
ZIKA VIRUS DISEASE

RULE IN RULE OUT

 Headache  Low grade fever
 Myalgia  Malaise
 Arthralgia  Itchy maculopapular rash
 Vomiting  Hematospermia??? (FEMALE IMO PX)
 (Nonpurulent?) Conjunctivitis  Hearing impairments
COVID-19: Basis for R/I
1. Local transmission in Tacloban
City
2. Fever
3. headache
4. Myalgia
5. Arthralgia
6. Sore throat
7. URTI
8. Conjunctivitis
9. Poor appetite
10. Vomiting

Source: (for # 2 to 10)

https://www.who.int/emergencies/di
seases/novel-coronavirus-
2019/coronavirus-disease-answers?
adgroupsurvey=%7Badgroupsurvey
%7D&gclid=Cj0KCQjwkbuKBhDRARIsA
ALysV7JBEhvupkXGfv9QCWxMqAFu7
59boJ6dP15L0A3OXFh0jWM5Ttic2IaA
jDUEALw_wcB&query=What+are+the
+symptoms+of+COVID19%3F&referre

11. Pleural effusion (notable

decreased breath sounds, vocal
and tactile fremitus mid basal R
lung field)
Source:

12. Tachypnea (RR=28cpm) https://bmcinfectdis.biomedcentral.c

13. Tachycardia (HR=120bpm) om/articles/10.1186/s12879-021-
14. Poor pulses and with cold and 05856-8
clammy extremities

Source:
https://www.nature.com/articles/s41371-020-0387-4
 15. Hepatomegaly

https://ejrnm.springeropen.com/articles/10.1186/s43055-
020-00317-9

CHIKUNGUNYA FEVER

RULE IN RULE OUT

 Fever  Migratory polyarthritis
 Severe arthralgia  Rash Maculopapular rash on upper
 Abdominal pain extremities and face, appearing at the time
 Anorexia of defervescence
 Headache
