1. A Case of N.E. 16 y.o Male cc: fever x 3 days

2. History of Present Illness
(-) epistaxis
(-) gum & aural bleeding
(-) hematemesis
(-) hematuria
(-) hematochezia
(-) melena
(-) petechiae/ ecchymoses/ rash
Px has a neighbor diagnosed with Dengue
3 days PTC:
(+) fever with chills (Tmax 39.5ºC)
(+) headache
(+) generalized weakness
(+) myalgia
(+) sore throat
(+) cough with productive sputum (whitish)

3. History of Present Illness
(-) calf pain
(-) abdominal pains
(-) jaundice
(+) good urine output
(-) hx of wading through the floodwaters
3 days PTC:
(+) fever with chills (Tmax 39.5ºC)
(+) headache
(+) generalized weakness
(+) myalgia
(+) sore throat
(+) cough with productive sputum (whitish)

4. History of Present Illness
Medications taken:
Paracetamol 500mg/tab every 4 hours for fever with minimal relief
3 days PTC:
(+) fever with chills (Tmax 39.5ºC)
(+) headache
(+) generalized weakness
(+) myalgia
(+) sore throat
(+) cough with productive sputum (whitish)

5. Review of Systems (-) dizziness (-) difficulty of breathing
(-) chest pains
(-) palpitations
(-) weight loss >20%
(-) decrease in appetite

6. Past Medical History
(-) hypertension, diabetes, liver, lung and kidney disease
(-) asthma, allergies to food and drugs
(-) previous hospitalizations and surgeries

7. Birth and Maternal History
Pt was born FT at Fabella hospital by an OB-Gyne via SVD to a then G1P0 mother.
(-) maternal illness, exposure to chemicals, radiation
(-) exposure to measles and varicella infection

8. Immunization History completed the EPI c/o LHC
(+) MMR c/o private pediatrician

9. Nutritional History
Px was fed with both breastmilk and formula since birth.
The patient’s current diet consists of rice, meat, fish, poultry, with minimal fruits and vegetables

10. Personal and Social History
H - good rel’p with parents & siblings
E - 2nd year HS, satisfactory performance, (-) failing grades
A - basketball, computer games
D - no use of illicit drugs
S - has groups of friends in school and neighborhood
S - not sexually active
S - no suicidal thoughts

11. Personal and Social History
Non-smoker, occasional alcoholic beverage intake
Px lives with his mother and 2 other siblings at home in Pasay City
Mother is the breadwinner of the family and works in a factory
Px’s family gets monthly stipend from relatives who work abroad

12. Genogram
HPN
CVD
Asthma
PTB 9 7 16 32 30 27 24

13. Physical Examination BP 90/60 HR 120s RR 20 T 38.6
Px is awake, coherent, oriented, weak-looking
Pinkish conjunctivae, anicteric sclerae, (+) pharyngeal injection, (-) cervical lymphadenopathies, (-) anterior neck masses, (-) nasoaural bleeding, (-) gum bleeidng
Equal chest expansion, clear breath sounds, (-) wheezes, (-) crackles, (-) retractions
Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs
Soft and flat abdomen, normoactive bowel sounds, (-) masses/ tenderness, liver and spleen nonpalpable
Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-) clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses, (-) calf tenderness, (+) flushed skin

14. Tourniquet Test
negative (<20 spots in 1 square inch)

15. Assessment
R/O Dengue Fever/ Dengue Hemorrhagic Fever

16. Plan For CBC with platelet count
Paracetamol 500mg/tab 1 tab every 4 hours for fever
Tepid sponge bath
Supportive therapy
Increase oral fluid intake
Avoid dark colored foods
WOF bleeding episodes

17. Questions Questions…..
What if the CBC was normal? It has only been a 3 day Hx of fever..
A negative tourniquet test doesn’t necessarily r/o DF/DHF.. What now?
Its too early to say.. What can we do at this point? Is watchful waiting enough to prevent the complications of DF/DHF?
Recent dengue cases are noted to be more virulent than the past (cross-immunities etc)

18. DF/DHF Epidemiology
10,383 cases of DF/DHF noted by Nat’l Epidemiological Center of DOH (Jan-June 20)
104 deaths (case fatality of 1%)
Most cases were at NCR, Region 4A, 5,6
Most deaths are caused by complications secondary to DHF and DSS
Most are diagnosed LATE

19. Bio-Rad Dengue NS1 Antigen Test
New offer at PGH Central Lab!!
Used in private hospitals since 2007
serum
available in minutes
May detect 4 dengue serotypes in the first 5 days of viremia (febrile phase)

20. Diagnostic Dilemma
P - pediatric patients with clinical signs of Dengue Fever, in the first 3 days of fever
I - Dengue NS1Antigen test
C - virus isolation test
O - sensitivity and specificity in diagnosis of Dengue Fever
M - cross sectional study

21. Clinical Question (Diagnostics)
What is the sensitivity and specificity of Dengue NS1Antigen test versus a viral isolation test in the diagnosis of DF/DHF in pediatric patients with clinical signs of DF in the first 3 days of viremia in a cross sectional study?

22. Therapeutic Dilemma
P - Pediatric patients with clinical signs of systemic viral infection (SVI)
I - Immunologicals
C - placebo
O - shortening the course of the disease
M - RCTs

23. Clinical Question (Therapeutics)
In pediatric patients with clinical signs of systemic viral infection, is there a significant difference in giving immunologicals versus placebo in shortening the course of fever seen in randomized controlled trials?