Dengue

1. CASE PRESENTATION
(GROUP 1)
• Ahmad Zulhakim B Mokhtar
• Muhammad Halmi B Faisal Thena
• Wan Nur Aima Nabila Bt Wan Mohd Zuferi
• Liyana Bt Roslan
• Norhabsah Bt Omar
• Noor Alieya Syafikha Bt zakaria
• Mahzalena Bt Aziz’s

2. PATIENT DEMOGRAPHIC
DETAILS
Name SF
Age 22 years old
Gender Female
Ethnic Group Malay
Religion Islam
Occupation Student
Ward 4D at Hospital Sungai Buloh
Date of
Admission
19th November 2015
Date of
Discharge
22nd November 2015

3. CHIEF COMPLAIN
SF, a 22 years old Malay young lady presented to
Emergency Department with complaint of fever for
six days & gum bleeding for five days prior to
admission.

4. History of Presenting Illness

5. At PALAM
(before 7/11)
At home,
Mantin
(7/11-15/11)
13/11
(Friday)
16/11
(Monday)
17/11
(Tuesday)
18/11
(Wednesday)
19/11
(Thursday)
21/11
(Saturday)
FEVER
HEADACHE
CLERK

6. Symptoms in chronological order
based on which comes first

7. Fever (6 day before admission)
• On/off
• High grade fever (not recorded) -1st day
• Sudden onset
• Headache, chill, lethargy, muscle pain (myalgia), joint pain (arthralgia), dehydration
• No rigor, no retro orbital pain, no fits
• Worsen during night
• Relieve temporarily – Panadol
• No travelling history, no history of contact with ill patient
• Start on 13/11/15, at home in Mantin

8. Headache (6 day before admission)
• Left frontal area
• Intermittent
• Throbbing in nature
• Dizziness
• No visual disturbance, no photophobia, no altered emotional status, no seizures noted
• Happen more at night and lasts for 5-8 minutes
• Worsen on doing activity
• Relieve by sleeping
• End with fever

9. Gum bleeding (5 days before admission)
• Previously, bleeding when brushing teeth
• Unprovoked gum bleeding (5th day - morning)
• Very small amount
• No pain
• Occur in short of time

10. Diarrhea (2 Days before Admission)
(Happens for 1 day only)
• Watery stool
• Dark brown (She claims that this is the normal color)
• 2-3 times in 1 day (5th day)
• Have abdominal pain
• No pain during passing stool
• No presence of blood and mucous
• No abdominal distended
• No flatulence

11. Vomit (1 day before admission)
• 3 times in a day (6th day)
• Vomits Content:
– Presence of food –after eat
– Presence water
– About 100 ml
• Felt nausea before vomiting (Non-projectile)
• No blood

12. Rash (1 day before admission)
• Appears suddenly
• Pruritic rash
• All parts of body (except face and neck)
• Start on 8th day- waking up on morning

13. SYSTEMIC REVIEW
System Symptoms
General Lethargy, loss of appetite, no loss of weight
Gastrointestinal Diarrhea, no abdominal pain, no constipation, no hematemesis
Cardiovascular No palpitation, no chest pain, no dyspnea on exertion, no orthopnea
Respiratory No shortness of breath, no cough, no hemoptysis, no runny nose
Central nervous Headache, no loss of consciousness, no seizure, no hearing and
vision problem
Musculoskeletal Arthralgia, myalgia, no stiffness, no swelling
Genitourinary No urinary incontinence, no hematuria, no loin pain, no nocturia
Hematological Gum bleeding, rashes, no bruises, no nose bleed

14. PAST MEDICAL HISTORY
• 1st hospitalization
• No known chronic illness

15. • Not on any medication or supplements
• Not take any traditional medication or herbs
• No known allergic
DRUG & ALLERGIC HISTORY

16. FAMILY HISTORY
• Mother died due to leptospirosis in 2009
• Her father still alive and had no chronic illness
• 1st out of 4 siblings
• All are well
• Younger brother also had history of DF last month

17. SOCIAL HISTORY
• Single
• Studied at UiTM Puncak Alam
• Lives in Fasa 3 Puncak Alam during open semester
• Lives in Mantin, Negeri Sembilan during semester break
• Non-smoker
• Non-alcoholic
• Not take any recreational drug

18. GENERAL EXAMINATION
• Ms SF was laying comfortably, propped up at 45⁰ and
supported with a pillow. She was conscious and alert to
person, place and time, not in pain or in respiratory
distress with respiratory rate 20 breaths/minute. There
was no gross deformity and abnormal movement. Her
nutritional and hydrational status was fairly well.
Vital Sign ( On the day of admission)
• Temperature : 38 C
• BP : 109/75
• Pulse rate : 72
• Respiratory rate :24

19. ANTROPOMETRY
• Weight : 47 kg
• Height : 155 cm
• BMI : 19.56 kg/m2
Impression: Normal BMI

20. HAND EXAMINATION
• Warm and dry
• No clubbing, no cyanosis, no splinter
haemorrhage, no janeway lesion, no palmar
erythema.
• Capillary filling time is less than 2 second

21. EYE, ORAL CAVITY, EAR, NOSE
• Eyes :
– No conjunctiva pallor, jaundice
• Oral cavity :
– Gum bleeding
– No central cyanosis
– Good oral hygiene
• Ear and Nose :
– No runny nose,
– No nasal discharge

22. NECK, FACE, LEGS
• Neck and face :
– No palpable lymph nodes at neck, no thyroid
enlargement, JVP not raised
– No rashes on face, no facial erythema
• Legs :
– No edema
– Bilaterally rashes

23. SYESTEMIC EXAMINATION
• Respiratory system :
o Respiratory system
revealed normal
findings on both
lungs. The chest
expansion is
symmetrical and
trachea is located
centrally without any
deviation. Tactile
and vocal fremitus
are normal.
• Cardiovascular
system:
o Shape of chest is
normal, no surgical scar,
no visible pulsation and
no pericardial bulge.
o Apex beat is palpable at
5th intercostal space but
slightly displaced to the
left. There are no heave
and thrill.
o Percussion shows
normal cardiac dullness.
o On auscultation, first and
second heart sounds
were heard at all 4 areas
without any additional
sounds.

24. • Abdominal system
o Not distended and
moves symmetrically
with respiration. The
umbilicus was centrally
located and inverted.
No scar, no skin
pigmentation and
superficial dilated vein
noted.
o Soft and non-tender.
Liver and spleen was
not palpable. Kidney
were not ballotable
o No shifting dullness or
fluid thrill noted.
o Normal bowel sound.
• Musculoskeletal system
o There was no muscle
wasting of thena and
hypothena muscles
o No findings of bony
deformities, no signs of
inflammation, all
movements are normal

25.  Central Nervous System
o Mental status : She is alert, conscious and well
oriented to time, place and person. She recognized
people well. She looked calm and not in the state of
depression. She answered questions accordingly.
o All cranial nerves are intact.
o Motor system : Muscle looks symmetrical, no
fasciculation and no over weakness. No abnormal
movements were noted. Muscle tone was normal and
muscle power was 5/5. Coordination was normal.
Reflects were normal and present bilaterally

26. CASE SUMMARY
• Ms SF, a 22 years old Malay young lady came from a dengue hotspot
area was presented to Health Care Unit of UiTM Puncak Alam on 16th
November 2015 with a chief complaint of unresolved fever for 6 days
duration associated with intermittent headache, chills, myalgia,
arthralgia, dehydration and lethargy and was admitted on 7th day of
fever after the result of blood taken showed a low level of platelet
count suggestive of dengue fever.
• The fever also associated with nausea, vomitting and diarrhea. She
had gum bleeding that start 5 days prior to admission .
• On physical examination, no abnormalities were noted.

27. Provisional Diagnosis
Dengue Fever
Point to Support
– Fever for 7 days with chills and rigor
– Arthralgia and myalgia
– Headache
– Nausea and Vomitting
– Bleeding tendecy
– Living in Dengue Hot Spot area
– Current family history of dengue

28. Differential Diagnosis
Diagnosis Points to support Points to against
Leptospirosis - Fever
- Myalgia
- No history of working or bathing in
muddy or stagnant water or handling
animals.
- No conjunctiva infection
- No abdominal pain
- No jaundice
Malaria - Fever
- Vomiting
- Myalgia
- No paroxysm
- No jaundice
- No history of travel
- No jaundice
- No neurological symptoms

29. Differential Diagnosis
Chikungunya - Fever
- Myalgia
- Vomiting
- No extremely painful joint pain
- No eye inflammation
Typhoid infection - Fever
- Lethargic
- Headache usually at the frontal and
dull in nature
- No recent travel/ denied eating
outside for the last few weeks
- No changes in bowel habit
- No rose spot

30. Investigation

31. Results Normal range Interpretation
WBC 3.1X 109 /L 4-11 X 109 /L Decreased
RBC 4.59 X 1012 /L 4.5-6.5 X 1012 /L Normal
Hb 13.5 g/dL 13-18 g/dL Normal
MCV 90.0 fl 86-96 fl Normal
MCH 29.4 pg/cell 27-33 pg/cell Normal
MCHC 32.7 g/dL 30-35 g/dL Normal
Red cell distribution
width
13.5% 11.5-14.5% Normal
Plalelet 49X 109 /L 150-400 X 109 /L Decreased
% lymphocyte 55.2% 20.0-45.0 % Increased
% monocyte 17.5% 2.0-10.0 % Increased
% neutrophil 18.0% 40.0-75.0 % Decreased
% eosinophil 1.8% 1.0-6.0 % Normal
% basophil 7.5% 0.0-1.0 % Increased
Full blood count (FBC)

32. Liver Function Test
Content Result Normal value Interpretation
Total protein 71.0 g/L 60 – 80 g/L Normal
Albumin 38 g/L 35 – 50 g/L Normal
Total bilirubin 6.7 umol/L 3 – 17 umol/L Normal
Alkaline
transaminase
34 U/L 5 -35 U/L Normal
Alkaline
phosphatase
38 U/L 30 – 150 U/L Normal

33. Renal Profile
Content Result Normal value Interpretation
Urea 2.6 mmol/L 2.5 – 6.7 mmol/L Normal
Sodium 134 mmol/L 136 – 144 mmol/L Slightly Low
Potassium 3.5 mmol/L 3.50– 5.30 mmol/L Normal
Chloride 99.0 mmol/L 98.0-107.0 mmol/L Normal
Creatinine 57.1 umol/L 50.0 – 98.0 umol/L Low

34. Coagulation Profile
Result Normal range Interpretation
Prothrombin time
(PT)
11.8 sec 10-14 sec Normal
International
normalised ratio
(INR)
1.05 sec <1.5 Normal
Activated partial
thromboplastin time
(aPTT)
39.2 sec 20-35 sec Normal

35. Venous Blood Gas
Content Result Normal Value Interpretation
pH 7.409 7.32-7.42 Normal
PaO2 27.4 mmHg 28-48 mmHg Slightly Low
PaCO2 40.3 mmHg 38-52 mmHG Normal
HCO3 25.0 mmol/L 24-30 mEq/L Normal
Oxygen Saturation 48.3% 50-70% Slightly Low

36. Cardiac Enzymes
Content Result Normal value Interpretation
AST 89 U/L 5 – 34 U/L High
Lactate
dehydrogenase
449 U/L 125 – 220 U/L High
Creatinine Kinase 80 U/L 25 – 195 U/L Normal

37. Serology
Type Results
NS1Ag Positive
IgM/IgG Negative

38. Final Diagnosis
• Dengue fever with 7 days of fever and warning
signs such as thrombocytopenia and bleeding
tendecy.

39. Meal Time Type of Food Portion Size kCal Times/week
Breakfast  Fried rice
 Milo
 Half cup of rice
 1 cup
265
65
Almost
everyday
Lunch  Rice
 Chicken soup
 Vegetables
 Plain water
 1 cup of rice
 1 bowl
204
200
58
65
Almost
everyday
Dinner  Rice
 Chicken soup
 Vegetables
 Plain water
 1 cup of rice
 1 bowl
204
200
58
65
A few times
TOTAL 1384 kcal
DIET HISTORY
No history of eating out
None of her housemates in have diarrhea of any
acute gastroenteritis symptoma

40. WARNING SIGNS !
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation (pleural effusion, ascites)
Mucosal bleed
Restlessness or lethargy
Tender enlarged liver
Laboratory : Increase in HCT concurrent with rapid
decrease in platelet

41. CRITERIA FOR HOSPITAL REFERRAL / ADMISSION
1. Symptoms :
 Alarm signals
 Bleeding manifestations
 Inability to tolerate oral fluids
 Reduced urine output
 Seizure
2. Signs :
• Dehydration
• Shock
• Bleeding
• Any organ failure
3. Special Situations :
• Patients with co-morbidity
• Elderly (> 65 years old)
• Pregnancy
• Social factors that limit
follow-up
4. Laboratory Criteria:
 Rising HCT + ↓ platelet
count

42. MANAGEMENT
1. FLUID THERAPY
 Obtain a baseline HCT before fluid therapy.
 Give crystalloids solution (such as 0.9% saline).
 Start with IVD 5cc/kg/hour for 2 hours.
 Cont. reduce to 3cc/kg/H for next 2 hours.
 Cont. reduce to 2cc/kg/H

43. 2. MEDICATIONS
 Tranexemic gargle
 IV maxolone 10mg PRN

44. Discussion…

45. Virology
• Dengue infection is caused by dengue virus which is a mosquito-borne flavivirus
– 4 Distinct type:
• DEN-1
• DEN-2
• DEN-3
• DEN-4
• It is transmitted by
– Aedes aegypti and Aedes albopictus

46. EPIDEMIOLOGY

47. CLINICAL COURSE OF DENGUE INFECTION

48. DISCHARGE CRITERIA