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THE CASE
4 days PTA
Patient
woke
up
undocumented fever
with
4 days PTA
She took:
1. Phenylephrine HCl + Chlorphenamine
maleate + Paracetamol (Bioflu) 500
mg/ tab every 6 hours for the fever
and headache
2. Ibuprofen
+
Paracetamol
200mg/325mg (Alaxan FR)
for
myalgia and arthralgia
Afforded no relief
2 days PTA
Still with above symptoms now
dizziness & sudden onset of Abdominal
pain, burning in quality, epigastric in
location, radiating to the right upper
quadrant, severity of 9/10, aggravated
by food intake and relieved by vomiting
Reported loss of appetite
2 days PTA
3 episodes of vomiting of:
previously ingested food, non-bilious,
non-bloody, watery, and approximately
100 cc in volume.
Self-medicated Simethicone (Kremil S) x
1 dose afforded no relief of abdominal
pain
There was no change in bowel movement,
melena, hematochezia, hematemesis
No consult done
1 day PTA
Fever subsided, but persistence of
abdominal pain and headache noted
which progresses from 9/10 to 10/10
Persistence of symptoms prompted
consult
FAMILY HISTORY
No hypertension, no DM,
Bronchial asthma
No kidney, liver, or thyroid
disease
No Cancer
OB History
G2P1 1-0-1-1
1 living child delivered via NSD
(OMMC,2008)
S/P salpingo-oophorectomy, left,
secondary to ectopic pregnancy
(2014, PGH)
Menstrual History
Menarche at 9 years old
Average of 4 napkins a day,
soaked
No history of dysmenorrhea
SEXUAL HISTORY
Had 3 heterosexual male partner
First coitus at 14 y/o
Currently have 1 heterosexual male
partner
No history of artificial contraceptive
method use
Fluid intake:
~500ml of Water/day (2 cups)
3
bottles
of
Coke
(8ounces/bottle)
ActivityExercise
Sedentary lifestyle
Pattern:
REVIEW OF SYSTEMS
PHYSICAL EXAM
GENERAL SURVEY
J.D. was awake, alert and
coherent and oriented to 3
spheres
Calm, no signs of
cardiorespiratory distress
Ambulatory
Ectomorphic
VITAL SIGNS
T: 35.4C (axillary)
PR: 68/MIN
RR: 15cpm
BP: 110/70 mmHg (sitting)
ANTHROPOMETRIC
Height: 1.54 meters
Weight:46kg
BMI: 19.39 (Normal)
SKIN
Light brown in color with sparse
hair, evenly distributed on all
extremities
No noticeable change in skin color
No rash, erythema, purpura,
ecchymosis
warm to touch
pinkish nail beds
Tourniquet test negative
HEAD
Normocephalic atraumatic
(NC/AT)
Hair was naturally black in
color ; texture is fine and with
normal hair distribution
No palpable lesions, masses or
tenderness
EYES
No protrusions, retraction, drooping
or edema in the eyelids.
(-) lesions, masses and periorbital
edema and tenderness
Visual acuity: OD: 20/20 OS: 20/20
visual fields intact
Sclerae white in color, (-) abrasions
Pale and moist Palpebral
conjunctivae
EYES
Pupils equal at 3 to 2mm both
responsive to light and
accommodation
Irises dark brown; no signs of cilliary
injections.
Extraocular muscle movements
intact
No tenderness on lacrimal apparatus
EARS
Bilateral kidney-shape pinna
No deformities, lesions, masses
Intact tympanic membrane, cone of
light pointing antero-inferiorly.
No pain on tug-test
(+) whispered voice hearing test :
R=L
NOSE
Nose and nasal septum midline
Patent nostrils
Frontal and maxillary sinuses nontender
THROAT
Pinkish Lips
With dental caries , incomplete set of
teeth
Pinkish buccal mucosa and gums ,No
bleeding
No ulcerations, inflammation or
bleeding
Non-inflammed Tonsils
Tongue and uvula midline
NECK
No asymmetries or masses
Non-palpable thyroid gland
No neck vein distention
Non palpable cervical lymph nodes
HEART
Adynamic precordium
No thrills, lifts or heaves
PMI: 5th left ICS LMCL 1.5
diameter
Base: S1 > S2
Apex: S2 > S1
S3 and S4 absent
No murmurs, no extra sounds
ABDOMEN
Shape: globular
Inverted umbilicus
Symmetrical, with vertical surgical
scar below the umbilicus,healed
No dilated veins
No visible peristalsis or pulsations
Bowel sounds: normoactive (23/min)
No bruit, thrills
ABDOMEN
Tympanitic on all four quadrants
Liver span at 6cm X 9cm
(+) epigastric pain on percussion and
palpation (direct palpation)
Negative Murphys sign
Negative Rovsings, Psoas, Obturator
sign
Spleen non-palpable
No CVA tenderness
EXTREMITIES
Arms and legs: symmetrical, warm,
no edema
No hematoma
Capillary refill: 2sec upper and
lower
Peripheral pulses: symmetric arms
and legs (2+ brachial, radial,
popliteal and dorsalis pedis)
No limitation ROM
MUSCULOSKELETAL
Muscle bulk: symmetrical, good
tone both upper and lower
No gross involuntary movements
or atrophy
Ambulatory, able to stand, slow
steady gait
Usually sitting: upper body
leaning forward
Muscle strength: 4/5 upper, 5/5
lower
NEUROLOGIC EXAMINATION
CRANIAL NERVE
CRANIAL
INTERPRETATION
NERVE
Able to smell coffee beans on both nostrils.
I
OD:20/20
OS: 20/20
II
Pupils are equally reactive to light (32mm) with direct and
consensual light reflex, (+) accommodation
III
IV
VI
CRANIAL NERVE
CRANIAL
NERVE
VII
VIII
IX
X
INTERPRETATION
Bilaterally symmetrical face
Can raise eyebrows, wrinkle forehead, close eyes tightly, and puff
cheeks.
Intact gross hearing
Intact gag reflex
No hoarseness in voice
Uvula is in midline.
XI
XII
MOTOR
Symmetric muscle bulk of proximal and
distal muscles of both upper and lower
extremities.
No atrophy of muscles.
No clonus, fasciculations, seizures,
tremors, and spasm.
No involuntary movements
Arms and legs can be extended
throughout the range of movement.
No rigidity, spasticity, or flaccidity.
MUSCLE STRENGTH
Muscle strength on upper and lower
extremities are as follows:
LUE
LLE
5/5
5/5 RUE
5/5
RLE
5/5
SENSORY
LUE
100%
LLE
100%
RUE
100%
RLE
100%
Intact
pain,
light
touch,
superficial
sensation, deep sensation and vibratory
sensation on both plantar surfaces of feet,
fingertips and both U and Lextremities
Number identification, point localization and
extinction on both R and L sides were intact
REFLEXES
REFLEXES
Biceps
Triceps
Brachioradialis
Knee
Ankle
RIGHT
+2
+2
+2
+2
+2
LEFT
+2
+2
+2
+2
+2
SALIENT FEATURES
Headache (fronto-temporal,
throbbing, 5/10)
Myalgia and arthralgia
No
No
No
No
rashes
chest pain, orthopnea, PND
dysuria, no oliguria, no hematuria
easy bruisality
SALIENT FEATURES:
PERTINENT POSITIVE FROM PE
VS: 100/70 93 20 36.495%; BMI =
19.5 kg/m2
Abdomen: Flat, (+) midline incision on
hypogastrium, hypogastric area,
23 bowel sounds per minute,
Liver span: 6 x 9 cm, (+) epigastric
tenderness upon percussion and palpation
APPROACH TO DIAGNOSIS
Fever
Abdominal
Pain
Acute
Chronic
Noninfectious
Infectious
Dengue
Fever
Leptospirosis
Typhoid
Fever
Appendicitis
Gastrointesti
nal
Genitourinary
Cholecystitis
Pelvic
Inflammator
y Disease
Pancreatitis
DIFFERENTIAL DIAGNOSIS
RULE OUT
Fever
Abdominal pain
ACUTE APPENDICITIS
RULE IN
RULE OUT
Fever
Loss of appetite
Episodes of vomiting
ACUTE CHOLECYSTITIS
RULE IN
Female
Fever
Episodes of vomiting
Epigastric pain
(radiates to RUQ)
RUQ tenderness
RULE OUT
Pain is not generalized
on the right upper
abdomen
Pain does not radiate
to the interscapular
area, right scapula, or
shoulder
Does not present with
Myalgia and arthralgia
(-) Murphys sign
ACUTE PANCREATITIS
RULE IN
Fever
Abdominal pain
Nausea and vomiting
RULE OUT
No radiation to the back
Absent abdominal
distention
Absent muscle rigidity
Patient has normoactive bowel sounds
Myalgia and arthralgia
(-) Cullens sign
(-) Turners sign
LEPTOSPIROSIS
RULE IN
RULE OUT
Fever
Abdominal pain
Nausea and vomiting
Myalgia
TYPHOID FEVER
RULE IN
RULE OUT
No history of prolonged
fever for up to 4 weeks if
untreated
Absence of
maculopapular rash (rose
spots)
No change in bowel
movement
(-) Hepatosplenomegaly
Normal heart rate during
time of fever
Fever
Abdominal pain
Headache
Myalgia and arthralgia
Anorexia
Nausea and vomiting
Abdominal tenderness
DENGUE FEVER
RULE IN
Fever
Abdominal pain
Headache
Persistent nausea and
vomiting
Myalgia and arthralgia
RULE OUT
APPROACH TO
DIAGNOSIS
PATHOGENESIS
PATHOGENESIS
A. aegypti
Environmental Risk
Factors/ Breeding sites
1. Stagnant flood
water
2. Flower vases/pots
3. Piles tires
DENGUE : PATHOGENESIS
A. aegypti
BITE OF A VIRUS carrying
mosquitoSkin
Environmental Risk
Factors/ Breeding
sites
1. Stagnant flood
water
2. Flower vases/pots
3. Piles tires
Blood
Infect cells
Infection Immune response
Stimulates release of
cytokines
Activation T cell
response (memory T cell
if re-exposure
Neutralize pre-existing
antibody
Virus-antibody complex
AB enhance uptake
Phagocytosis
High fever,
body
weakness,
headache and
dizziness
Cytolysis
Vasculopathy
(Plasma
leakage)
Coagulopathy
(PTT/APTT)
Complement system
activation
Vascular endothelial
activation
THROMBOCYTOPENIA
HEPATOSPLENOME
GALY
DENGUE HEMORRHAGIC
The Investigation:
Laboratory and Diagnostic Procedures
THE INVESTIGATION:
LABORATORY AND
DIAGNOSTICS
3 PHASES OF DENGUE
FEBRILE PHASE
Lasts 2-7 days
Monitoring for warning
signs is crucial
Mild hemorrhagic
manifestations
Progressive decrease in
WBC earliest
abnormality
Tourniquet test
CRITICAL PHASE
CRITICAL PHASE
Warning signs:
Increase in capillary
fragility
Beginning of critical
phase
Severe Dengue:
1. Plasma leakage and/or
fluid accumulation
respiratory distress
2. Severe bleeding
3. Severe
organ
Clinical
problems
encountered:
Shock
from the plasma leakage
impairment
Severe hemorrhage
Organ impairment
CRITICAL PHASE
Dengue shock:
critical volume of plasma is lost through
leakage
Preceded by warning signs
Temp: subnormal
Prolonged shock organ hypoperfusion
organ impairment, metabolic acidosis,
DIC severe hemorrhage dec Hct,
Clinical
problems
encountered:
inc
WBC
RECOVERY PHASE
Gradual re-absorption of extravasated fluid
(48-72 hours)
Patients general wellbeing improves,
hemodynamic status stabilizes and
diuresis ensues.
Hct stabilizes or may be lower (dilution
effect of reabsorbed fluid)
After defervescence: rise in WBC then
platelet
Clinical
problems encountered:
Hypervolemia
CBC
WBC
Neut
Lym
Mono
Eosi
Baso
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plt
BT c Rh
PT
Control
% Act
INR
PTT
4/8
2.2
62.3
22.2
15.5
0
0
4.7
15.2
41.1
87.4
32.3
37.0
12.9
226
4/9
AM
2.5
55.3
27.2
17.5
0
0
4.51
14.4
40.1
86.7
31.9
36.8
13.1
169
12.8
14.6
114.0
6
0.88
25.4
4/9 PM 4/10
AM
3.2
4.3
21
34.3
74
45
5
20.7
0
0
0
0
4.37
4.4
14.1
13.8
37.7
38.3
86.3
87
32.3
31.4
37.4
36
12.8
12.8
94
126
4/10 PM 4/11 AM
4.8
24.6
64.3
11.
0
0
4.16
13.2
35.9
86.3
31.7
36.8
12.8
97
6.9
15.7
69.3
15.0
0
0
4.05
13.1
35.6
87.9
32.3
36.8
12.5
187
1
STAGE
Febrile
TEMP.
4 (4/8)
5 (4/9)
admit
Critical
7 (4/11)
36.7
Lysis of
fever
Headach
e
Abdomin
al pain
Epigastri
c pain
Headach
e
No ab
pain
WBC
(inc)
2.2
2.5
3.2
4.3
4.8
6.9
PLT
COUNT
226
16
9
94
12
6
97
187
HCT
(dec)
41.1
40.
1
37.
7
38.
3
35.
9
35.6
Serology
Fever
Headach
e
Myalgia
Arthralgi
a
Fever
Headach
e
Myalgia
Arthralgi
a
Fever
Headach
e
Myalgia
Arthralgi
a
Abdomi
nal pain
Vomitin
g
36.7
36.5
FEVER
IgG +
8 (4/12)
DISCHARG
ED
Recovery
36.0
36.4
36.8
SSx
Undocumented
6 (4/10)
Ab pain
Epigastri
c pain
MANAGEMENT
ASSESSMENT
Presumptive Diagnosis:
Live in/travel to endemic
area +
Fever and 2 of the ff:
Anorexia and Nausea
Rash
Aches and pains
(myalgia, arthralgia)
Warning signs
Leucopenia
Tourniquet test
positive
Warning Signs:
Abdominal pain/tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy and restlessness
Liver enlargement >2cm
Lab: inc Hct concurrent with
rapid dec. of Pt count
Warning Signs
Coexisting conditions
Social circumstance*
Co-existing conditions
Social
that may make dengue
circumstances
or its management
more complicated
Pregnancy
living alone
infancy
living far from a
Old age
health facility
Obesity
without reliable
Diabetes mellitus
means of transport
Hypertension
Heart failure
Renal failure
Chronic hemolytic
diseases such as sicklecell disease and
autoimmune diseases
Warning Signs
Group Criteria
Patients who do
not have warning
signs
AND
who are able:
To tolerate
adequate
volumes of oral
fluids
To pass urine at
least once every
6 hours
DENGUE
WITHOUT
WARNING
SIGNS
GROUP A:
MAY BE
SENT
HOME
Coexisting conditions
Social circumstance*
Laboratory
Tests
Treatment
Monitoring
Full blood
Count (FBC)
Haematocrit
(Hct )
Advice for:
Adequate bed
rest
Adequate fluid
intake
Paracetamol, 4
gram max. per
day in adults
and
accordingly in
children
Patients with
stable Hct can be
sent home
ORAL REHYDRATION
NOTES:
Oral rehydration solution ( 3-4 sachet of
ORESOL in 1L of water) or soup and fruit
juices may be given to prevent electrolyte
imbalance.
Commercial carbonated drinks that exceed
the isotonic level (5% sugar) should be
avoided.
They may exacerbate hyperglycemia related to
physiological stress from dengue and diabetes
mellitus.
Warning Signs
Warning Signs
Coexisting conditions
Social circumstance
GROUP B:
REFERRED FOR
IN-HOSPITAL
ENGUE WITHOUT WARNING SIGNS CAREDENGUE WITH WARNING SIGNS
Group Criteria
Coexisting conditons/social
circumstance
OR
Existing warning signs:
Abdominal pain or
tenderness
Persistent vomiting
Clinical fluid
accumulation
Mucosal bleeding
Lethargy/ restlessness
Liver enlargement
>2cm
Laborato
ry Tests
Full
blood
Count
(FBC)
Haemat
ocrit
(Hct )
Treatment
(without
warning sign)
Encouragement
for oral fluids
If not
tolerated,start
intravenous
fluid therapy
0,9% saline or
Ringer Lactate
at maintenance
rate
Treatment
(with
Warning
signs)
See next
slide
MONITORING
MONITORING
(without warning
(with warning signs)
signs)
Vital signs and peripheral
Temperature pattern
perfusion (1-4 hourly until
Volume of fluid intake
patient is out of critical
and
phase
Losses Urine output
volume and frequency Urine output (4-6 hourly)
Warning signs
Hct (before and after fluid
replacement, then 6-12
Hct, white blood cell
hourly)
and platelet counts
Blood glucose
Other organ functions
(renal profile, liver profile,
coagulation profile, as
Warning Signs
Group Criteria
GROUP C:
REQUIRE
EMERGENCY
TREATMENT
SEVERE
DENGUE
Laboratory Tests
Treatment
Monitorin
g
See next
slide
Treatment of compensated
shock
DISCHARGE CRITERIA
All of the following
criteria must be
present :
No fever for 48 hours
Increasing trend of platelet
count
Stable hematocrit without
intravenous fluids
Improvement in clinical