General Data:

Name: MJ Age/sex: 7/M Religion: RC Address: De Gloria Extension, Area B, Batasan Hills Quezon City DOA: September 9, 2012 Informant: Father and Grandfather Reliability: 90%

Chief complaint:

VOMITING

HISTORY OF PRESENT ILLNESS

4 days PTA (+) Undocumented fever
(+) Epigastric pain 5/10 (+) vomiting of previously ingested food, non-projectile, non-billous, non-bloody, 3 episodes, approximately 4 tbsp/ep. No other associated symptoms noted Med: Paracetamol 500 mg/tab, temporary lysis of fever No consult

HISTORY OF PRESENT ILLNESS

3 days PTA
Persistence of symptoms (fever, vomiting, epigastric pain) (+) Myalgia (+) Rash (maculopapular rash) (+) Weakness Med: Paracetamol, did not provide lysis of fever No consult

HISTORY OF PRESENT ILLNESS

2 days PTA (-) melena, (-) hematochezia, (-) epistaxis, (-) nasal discharge Persistence of symptoms Went to a manghihilot Assessed to have pilay

HISTORY OF PRESENT ILLNESS

Few hours PTA Afebrile Persistence of other symptoms (vomiting, epigastric pain) (+) cold, clammy extremities Consult: Pedia ER-EAMC Platelet: 60

ADMISSION

REVIEW OF SYSTEMS
No weight loss, (+) loss of appetite, no headache No loss of consciousness No blurring of vision, no eye itchiness, no eye pain No deafness, no aural discharge, no tinnitus No dental caries, no sore throat no hempotysis No chest pain, no orthopnea, no PND, no palpitations No diarrhea, no constipation No polyuria, polydipsia, no polyphagia No urinary frequency, no urgency, no dysuria No behavioral changes, no depression, no anxiety

PAST MEDICAL HISTORY

No asthma, allergy, PTB No previous surgery No previous hospitalization

IMMUNIZATION HISTORY
Complete vaccination EPI till 9 months at local health center

FAMILY HISTORY
(-) HTN, DM, asthma, allergy TB father- treated for 6 months (-) cardiovascular diseases

Family Profile:
Name Age Educational Attainment Employment Health Status

AJ

33

HS grad

Housekeeper

Healthy

MJ
CJ C

26
5 4

HS grad

Housewife

Healthy
Healthy Healthy

Personal, Social and Environmental history:

Currently grade 1 student at Rodriguez Rizal Elem. School Has 2 siblings Lives with 2 parents in a 1 story house No noted dengue epidemic in their community

PHYSICAL EXAMINATION
Awake, irritable, hyposthenic, weak looking Vital signs: BP: Palpatory 60 (p5 85/52) CR: 116 bpm RR 23 cpm Temp 36.6C Weight: 18Kg Cold clammy skin, no jaundice, (+) maculopapular rash over the upper extremities Eyes: Pink palpebral conjunctiva, anicteric sclera, isocoric pupils, 2-3 mm ERTL Ears: No aural discharge, no deformities, no tragal tenderness Nose: midline nasal septum, no nasal discharge, turbinates not congested Mouth: moist buccal mucosa, no ulcers, no gum bleeding

PHYSICAL EXAMIANTION
Supple neck, no thyroid enlargement, no palpable cervical lymph nodes Symmetrical chest expansion, no retractions, clear and equal breath sounds Adynamic precordium, AB 4th LICS MCL, no heaves, no lifts, no thrills, S1>S2 at the apex, S2>S1 at the base, no murmurs Flat abdomen, non-distended, normoactive bowel sounds, (+) epigastric tenderness, no masses (-) CVA tenderness DRE: not done Weak pulses, cold extremities

Salient Features:
Subjectives:
7/M Batasan Hills, Quezon City (+) Vomiting (+) Undocumented Fever (+) Myalgia (+) Epigastric pain (+) rash (-) epistaxis, gum bleeding, Melena Unremarkable Past medical histroy

Objectives:
Awake, irritable, hyposthenic, weak looking Vital signs: BP: Palpatory 60 (p5 85/52) CR: 116 bpm RR 23 cpm Temp 36.6C Cold clammy skin, (-) gum bleeding (+) maculopapular rash over the upper extremities and lower extremities (+) epigastric tenderness Weak pulses, cold extremities Thrombocytopenia: Platelet: 60

Approach to Diagnosis
Symptom, sign or laboratory finding pointing to a group of diseases Fever and Maculopapular rash

Maculopapular Rash + Fever

Patient Measles Roseola Varicella Dengue

Age
Maculopapular rash lower extremities

No age predilection
Spreads from hairline downward, clearing as it spreads

9-12months
Discrete lesions that become confluent as rash spreads from hairline downward, sparing palms and soles

1-7 years
Macules evolving into papules, then vesicles, on an erythematous base; pustules then forming and crusting; lesions may involve scalp, mouth; intensely pruritic diffuse flushing; midway through illness, onset of maculopapular rash, begins on trunk and spreads centrifugally to extremities and face

Maculopapular Rash + Fever

Patient Fever Myalgia Epigastric Pain Signs of Hemodyn amic instability Vomiting Measles + + Roseola + + Varicella + + + Dengue + + + +

DENGUE
Patient
(+) Vomiting (+) Undocumented Fever (+) Myalgia (+) Epigastric pain (+) rash (-) epistaxis, gum bleeding, Melena Unremarkable Past medical history VS: BP: Palpatory 60 (p5 85/52); CR: 116 bpm ; RR 23 cpm ; Temp 36.6C Cold clammy skin (+) maculopapular rash over the upper extremities and lower extremities Weak pulses, cold extremities Thrombocytopenia: Platelet: 60

Dengue Fever
Acute febrile illness Headache Retro-orbital pain Arthralgia Rash Hemorhagic manifestations Leukopenia Supportive serology Confirmed: A case confirmed by laboratory criteria

Dengue Hemorrhagic Fever

Fever, or history of fever, lasting for 2-7 days, occasionally biphasic Hemorrhagic tendencies evidenced by at least one of the following: 1. (+) tourniquet test Petechiae 2. ecchymosis, 3. Purpura 4. Bleeding from the mucosa, GIT, injection sites or other locations 5. Hematemesis or melena Thrombocytopenia ( 100,000 cells/mm3 orless) Evidence of plasma leakage due toincreased vascular permeability, manifested by at least one of the following: 1. A rise in the hematocrit equal to or greater than 20% above average for age, sex, and populationb. 2. A drop in the hematocrit following volume replacement treatment equal to or greater than 20% of baseline 3. Signs of plasma leakage such as pleural effusion, ascites and hypoproteinemia

Dengue hemorrhagic fever

DHF I (+) Vomiting (+) Undocumented Fever (+) Myalgia (+) Epigastric pain (+) rash BP: Palpatory 60 (p5 85/52); CR: 116 bpm ; Temp 36.6C Cold clammy skin maculopapular rash Weak pulses, cold extremities Fever, Non specific constitutional symptoms (vomiting anorexia, abdominal pain) + Torniquet test DHF !! Grade I + spontaneous bleeding DHF III DHF !V Grade II + severe Grade II I+ bleeding + Irreversible shock circulatory failure + massive bleeding

ASSESSMENT
Dengue Hemorrhagic fever III

PLAN
PLR (line 1) and PNSS (line 2) CBC, APC, PT, aPTT, blood typing, Na, K, Cl For admission

CBC w/ APC
9/9/12 WBC Hgb Hct Neutrophils Lymphocytes Monocytes Platelet 4.3 188 0.55 0.63 0.31 0.06 60 9/11/12 6.0 124 0.361 0.39 0.57 0.04 25 9/12/12 5.1 112 0.320 0.73 0.24 0.03 140