PEDIATRICS II PRECEPTORIAL WRITTEN REPORT (PAPER CASE)

1st Semester AY 2022-2023

NAME: FAJARDO, K

GROUP: B1

Paper Case # 2

IDENTIFYING DATA:
C.R., 13/F, residing in Sta. Mesa, Chinese-Filipino, Roman Catholic, was admitted into UERM Hospital
for the second time last November 18, 2022.

SOURCE AND RELIABILITY:

The patient’s mother, with good reliability

CHIEF COMPLAINT:
Fever of five (5) days duration

HISTORY OF PRESENT ILLNESS:

The patient came in for a fever of 5 days duration.

5 days PTA, px experienced intermittent fever (Tmax: 38.9C) associated with persistent non-radiating
generalized epigastric pain PS 3/10, throbbing persistent headache PS 5/10 located within the
temple area and weakness. Symptoms were partially resolved by Paracetamol tablet taken as
needed 3-4 times per day. Symptoms would subside within 30 minutes to 1 hour after intake of
medication, then would recur.

4 days PTA, intermittent fever continued to occur (same temp as 5 days PTA) with increased severity
of epigastric pain PS 5/10, partially relieved by intake of Kremil S. Patient started to experience loss
of appetite and was noted to be irritable. In the interim, symptoms persisted and did not progress.
No additional symptoms were noted.

1 day PTA, px experienced the same symptoms and had one episode of vomiting.

On the day of admission, px felt nausea in the morning. Due to the fever still persisting, px went in
for consultation for the first time with Dra. Lopez, wherein CBC and UA were requested. Px was
advised to go to the ER after receiving the results of the requested labs since px was noted to have a
low platelet count. Hence, admission into our institution.

1
TEMPORAL PROFILE:

PEDIATRIC HISTORY:

Birth History: The patient was delivered at full term (weeks unrecalled), normal delivery at UERM
Hospital. The mother was a G1P1 (1001) and 31 years old at the time of the patient's birth.
APGAR score, birth weight and birth length were unrecalled. Px was admitted into hospital for
one week due to an unspecified blood infection. Px took and completed unrecalled antibiotics for
1 week and was discharged the next day. Mother had regular check-ups and had no infections nor
complications throughout the course of her pregnancy. She denied alcohol, tobacco and illicit
drug use during the pregnancy.
Feeding History: The patient currently has no food preference and eats 3 meals a day with 2
snacks in between meals. Px is allergic to shrimp and crabs.
Px was purely breastfed only for one month and was switched to formula milk due to the mother
not having any more milk supply. Px was on formula feeding until 2 years old and addition of
solids started at 6 months old. Px was noted to drink Tiki-Tiki vitamin supplement, yet duration of
intake was unrecalled.
Immunization History: The informant claims that the patient had complete childhood
immunizations received from the clinic of Dra. Honey Lopez, with all dates unrecalled. COVID-19
vaccination was also administered, completing 2 primary doses of Pfizer, with the last dose given
during March 2021.
Developmental History: The patient is a 13 year old currently enrolled as a Grade 8 student.
Informant stated that px is an honor student. Developmental history is at par with age.
Past Medical History: The patient was previously admitted twice already in the past. At 1 year
old, px was admitted for 7 days due to dengue fever. At 4 years old, px was admitted for 5 days
due to persistent diarrhea and was given IV fluid and no noted medications. Px was also noted to
have had pneumonia at 3 years old, and was given antibiotics as an out-patient when they sought

2
 out consultation at a clinic.
Family History: The patient’s maternal grandparents are both alive and healthy. The patient’s
paternal grandparents are both alive yet both have arthritis/joint pains. The patient’s mother has
no comorbidities. Father has hypertension and diabetes mellitus. Siblings have no other noted
diseases reported.
Social/Environmental History: The patient currently lives in a house with her parents and
siblings, paternal grandparents, and paternal uncle. House is located near a creek and was noted
to have adequate garbage disposal (twice a week) with potable water, access to electricity and
basic utilities. It was noted however that their 4 year old neighbor was admitted also due to
dengue.
HEEADSSS (for Adolescent patients)
Px lives with her parents, siblings, paternal grandparents and paternal uncle. Px was noted to
have her own room. She is an honor student, currently attending modular classes as a Grade 8
student. She was noted to have plenty of friends. They like spending time together to eat and
play badminton. Px currently has no food preference. Px likes to play badminton with friends and
only goes out during the weekends. Informant claims that px had no vices. Px is not in a
relationship, although she is fond of actors from Korean dramas. Px has no suicidal thoughts nor
depression and is noted to be in a safe environment at home.

PHYSICAL EXAMINATION UPON INTERVIEW:

General Survey: Awake, conversant, not in cardiorespiratory distress

Vital Signs: T: 36.9C RR: 20/min HR: 96/min

BP: 90/60 mmHg O2 sat: 99% at room air

Anthropometrics: Weight: 42 kgs

Height: 152 cm (z = above -1, Interpretation: normal)
BMI: 18.2 kg/m2 (z = above -1, Interpretation: normal)

Skin: Smooth, no cyanosis, no rashes, flushed with good skin turgor, positive tourniquet test

HEENT:
Head: No structural defects
Eyes: No eye discharge, conjunctivitis, redness; anicteric sclerae, pink palpebral conjunctivae
Ears: Patent ear canals, both ears, well-curved pinna
Nose: Patient nares, no flaring, septum at the midline
Throat: With palatal petechiae

Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs

Chest & Lungs: Equal chest expansion, no retractions, clear breath sounds

Abdomen: Flat, normoactive bowel sounds, (+) direct tenderness on the epigastric area, liver
palpable 2 cm below the costal margin

Extremities: Full and equal pulses, CRT > 2 seconds, warm upper and lower extremities

3
Neurologic Examination:

Mental Status Examination: The patient came in fairly nourished. She is weak-looking but attentive
with good eye contact. She seems worried with appropriate affect. Activity level is decreased. She
spoke in sentences and was cooperative during examination. She answered questions
appropriately, was oriented to 3 spheres and had intact memory. She says that she was brought to
the hospital because she had to be admitted.

Cranial Nerves: I - can smell coffee

II, III - 2-3 mm pupils, equally brisk and reactive to light
III, IV, VI - full EOMs
V - (+) corneal reflex, intact V1-V3 VII - no facial asymmetry
VIII - intact gross hearing, turns to sound
IX, X - able to swallow, (+) gag reflex
XI - good sternocleidomastoid tone, good shoulder shrug
XII - tongue midline with no fasciculations

Cerebellum: no dysdiadokinesia, no dysmetria, no nystagmus

Motor: 5/5 motor strength on all extremities with good muscle tone and bulk

Sensory: 100% on all extremities for pain and light touch

Reflexes: DTRs +2 on all extremities, no clonus, no Babinski

Meningeal: supple neck, no Brudzinski or Kernig signs

2) What important physical examination findings should be examined and explain why these
findings can support your diagnosis?

The patient presented with pain, fever and weakness for five days. The PE revealed that
she had CRT >2 seconds, positive tourniquet test, and palatal petechiae. Capillary refill time (CRT)
of more than 2 seconds is considered to be not within normal limits as the normal should be brisk
(<2 seconds), indicative of a stable circulation with regards to hemodynamic assessment. A
positive tourniquet test is a physical examination technique that is used to diagnose and identify
dengue disease. This clinical diagnostic method is used to determine a patient’s hemorrhagic
tendency and microvascular fragility. It is done by obtaining the patient’s blood pressure, inflating
the cuff to a point halfway between SBP and DBP, maintaining it for 2 minutes, then counting the
petechiae below the antecubital fossa[CDC]. A positive test is 10 or more petechiae per 1 square
inch. Palatal petechiae could be a mucocutaneous manifestation of dengue fever, although the
majority of patients with dengue do not commonly present with this finding.

4
3) ASSESSMENT: DENGUE FEVER
Dengue is a mosquito-borne viral disease transmitted by female mosquito (mainly Aedes
aegypti) bites. It is caused by a virus of the Flaviviridae family, which four distinct serotypes (i.e.
DENV-1, DENV-2, DENV-3 and DENV-4). Recovery from infection from one serotype is believed to
provide lifelong immunity against the same serotype. However, subsequent infections by one type
increases the risk of developing severe dengue. Dengue commonly breeds in natural containers (e.g.
tree holes) but it has also adapted to urban habitats, especially man-made containers with buckets,
mud pots, storm water drains, etc - making it a disease commonly found in dense populated urban
centers. Once the female Aedes aegypti lays her eggs, these eggs can be viable for several months in
dry conditions, then they will hatch when in contact with water.

Dengue can cause a wide spectrum of disease. This can range from subclinical disease (no
symptoms) to severe flu-like symptoms. Rarely, severe dengue can develop in individuals which may
present with complications such as severe bleeding, organ impairment and plasma leakage.
Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an
infected mosquito. Dengue is classified by the World Health Organization into 2 major categories: 1)
Dengue with/without warning signs and; 2) severe dengue. This sub-classification aids in the triage
for admission, close monitoring and prevention of severe dengue.

According to WHO, dengue should be suspected when a high fever accompanied by 2 of

the ff symptoms (severe headache, pain behind eyes, muscle and joint pains, nausea, vomiting,
swollen glands, rash) occur during the febrile phase (2-7 days). Afterwards, px enters a critical phase
for about 3-7 days after illness onset. Warning signs to look out for include: severe abdominal pain,
persistent vomiting, rapid breathing, bleeding gums or nose, fatigue, restlessness, liver enlargement
and blood in vomit or stool. Afterwards, the convalescent phase occurs which also requires close
monitoring should the warning signs appear.

The patient presented with a fever of 5 days duration with associated epigastric pain,
nausea and one vomiting episode. Additionally, the physical examination revealed a positive
tourniquet test, CR >2 seconds and palatal petechiae, which point the diagnosis towards dengue
fever. The patient was also noted to reside near a creek, possibly where a female Aedis aegypti could
lay her eggs. It was also noted that their neighbor was also admitted recently due to dengue.
Additionally, the patient was noted to have a low platelet count, which is usually seen in dengue
patients. Taking all of these things into consideration, the patient is highly suspected to have dengue
fever.

5
Differential Diagnoses

Disease Rule In Rule Out

Chikungunya (+) Fever (-) Joint pains

(+) Weakness (-) Polyarthralgia
(+) Headache (-) Rash

Typhoid fever (+) Fever (-) Rose spots

(+) Weakness (-) Relative bradycardia
(+) Headache

Leptospirosis (+) Fever (-) History of wading flood

waters

COVID-19 (+) Fever (-) No other household

(+) Nausea members exhibiting symptoms
(+) Vomiting (-) COVID-19 exposure

4) DIAGNOSTICS:
● Complete Blood Count - Hematocrit test in early febrile test establishes the
patient’s baseline hematocrit. A decreasing WBC also makes dengue more
likely. A complete CBC is also done to monitor the patient’s blood volume
(Hematocrit) and level of blood cells (platelets).
● Bleeding parameters: Bleeding time, PT PTT - to evaluate signs of bleeding
● Dengue RT-PCR: gold standard for diagnosing dengue. This is done to confirm
the diagnosis especially in patients with unusual manifestations.

MANAGEMENT PLANS:
• SUPPORTIVE PLAN
Since the patient presents with warning signs (i.e. epigastric pain, nausea,
vomiting), the patient should be referred for in-hospital management. The action
plan is as follows[Dengue Clinical Guidelines, WHO]:

● Obtain a reference hematocrit before fluid therapy. Give only isotonic solutions such
as 0.9% saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7 ml/ kg/hour
for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3
ml/kg/hr or less according to the clinical response.
● Reassess the clinical status and repeat the haematocrit. If the haematocrit remains
the same or rises only minimally, continue with the same rate (2–3 ml/kg/hr) for
another 2–4 hours. If the vital signs are worsening and haematocrit is rising rapidly,
increase the rate to 5–10 ml/kg/hour for 1–2 hours. Reassess the clinical status,
repeat the haematocrit and review fluid infusion rates accordingly.

6
 • THERAPEUTIC PLAN
Give the minimum intravenous fluid volume required to maintain good perfusion
and urine output of about 0.5 ml/kg/hr. Intravenous fluids are usually needed for only 24–48
hours. Reduce intravenous fluids gradually when the rate of plasma leakage decreases
towards the end of the critical phase. This is indicated by urine output and/or oral fluid
intake that is/are adequate, or haematocrit decreasing below the baseline value in a stable
patient[Dengue Clinical Guidelines, WHO].
Patients with warning signs should be monitored by health care providers until the
period of risk is over. A detailed fluid balance should be maintained. Parameters that should be
monitored include: [Dengue Clinical Guidelines, WHO]
● Vital signs and peripheral perfusion (1–4 hourly until the patient is out of the
critical phase)
● Urine output (4–6 hourly)
● Hematocrit (before and after fluid replacement, then 6–12 hourly)
● Blood glucose, and;
● Other organ functions (such as renal profile, liver profile, coagulation profile,
as indicated).
The discharge criteria are listed below[Dengue Clinical Guidelines, WHO]. All of the following
conditions must be present.
● Clinical:
○ No fever for 48 hours
○ Improvement in clinical status (general well-being, appetite,
hemodynamic status, urine output, no respiratory distress)
● Laboratory:
○ Increasing trend of platelet count
○ Stable hematocrit with IV fluids
• PREVENTIVE PLAN
Dengue is prevented through the use of insect repellents, wearing of long-sleeved
shirts and long pants and through the control of mosquitoes living inside and outside the home.
In addition to this, potential breeding sites (i.e. moist places, with unclean water) should be
destroyed in order to prevent egg laying or hatching within the community.
REFERENCES:
World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control.
World Health Organization. Dengue and severe dengue. Obtained from:
https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue#:~:text=Dengue
%20is%20a%20mosquito%2Dborne,yellow%20fever%20and%20Zika%20viruses.
Kanish et al. Mucocutaneous Manifestations of Dengue Fever. Obtained from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856380/
Centers for Disease Control and Prevention. Dengue Prevention. Obtained from:
https://www.cdc.gov/ncezid/dvbd/media/avoid-dengue.html#:~:text=Use%20insect%20repellen
t%2C%20wear%20long,the%20bites%20of%20infected%20mosquitoes.
Centers for Disease Control and Prevention. Tourniquet Test. Obtained from:
https://www.cdc.gov/dengue/training/cme/ccm/tourniquet%20test_f.pdf