1. Dengue Fever with Warning Signs

2. Objectives To identify warning signs seen in Dengue Fever To manage a case of Dengue Fever with warning signs

3. General Data J.M.G 6 years old Male Pasig City

4. Chief Complaint Fever of 2 days duration

5. HPI (+) Fever, highest recorded temperature: 39.7C No other signs and symptoms noted 2 days PTA

6. HPI (+) Episodes of fever unrelieved by paracetamol Accompanied by headache One episode of loose stools One episode of vomiting Decreased appetite Day of Consult ER Consult

7. HPI HR 118 RR 24 T 38.8 BP 90/60 CBC was done Dengue NS1 done: (+) Flushed Slightly sunken eyeballs, moist mucosa Clear breath sounds Regular cardiac rhythm Soft non- tender abdomen Full and equal pulses At the ER Admission

8. Review of Systems Headache No cough and colds, no weakness, no joint pains, no difficulty of breathing, no nausea or vomiting, no abdominal pain, no change in stool color

9. Past Medical History Asthma, last attack 2013, no maintenance medications No known allergy to food and medication

10. Family History Hypertension (paternal) Diabetes Mellitus Asthma

11. Birth and Nutritional History Born full term via NSD to a 26 year old G1P1 Birth weight 2.58 kg (AGA) No perinatal/neonatal complications Not breast fed, Enfalac, Weaned by 6 months, Current diet consist of rice, meat, fish and vegetables

12. Immunization *BCG *DPT/*POLIO (123 booster 1-2) *Hepa B (1-2-3) HiB (1-2-3 booster) MMR (1-2) *Measles Varicella Influenza

13. Personal Social Home: lives in Pasig City with parents, single child Education: Grade 2, favorite subject Science Activity: play, school, TV

14. At the Floors General Survey: Conscious, alert, coherent, not in cardiorespiratory distress Ht: 143 cm Wt: 38.5 BP: 100/60 HR: 106 RR: 24 Temp: 38.1 C

15. HEENT: anicteric sclerae, pink palpebral conjunctiva, no TPC, no nasal discharge, (-) CLADs, Chest/Lungs: symetric chest expansion, clear breath sounds, no rales and wheezes Adynamic precordium, Apex beat 4 th ICS MCL, normal rate, regular rhythm, no murmurs ABDOMEN: Flat, normoactive bowel sounds, soft, (–) tenderness, (-) masses Extremities: full and equal pulses, (-) edema, (-) cyanosis, good skin color and turgor, CRT<2 sec Skin: no rashes, no petechiae

16. Salient Features 7/M 2 day history of fever (+) headache No recurrence of vomiting or loose stools No bleeding, no rashes, no petechiae No hemodynamic compromise Dengue NS1 (+)

17. Admitting Diagnosis Dengue Fever without Warning signs ( WHO 2010)

18. Course in the Wards Day 1-2 (Day 2-3 of Illness) S> Still with febrile episodes, decreased appetite, no complaints of bleeding, no subjective complaints O> Awake, comfortable, flushed Clear breath sounds Regular cardiac rhythm No abdominal tenderness, Full and equal pulses, warm extremities, CRT< 2 sec A> Dengue fever P> IV hydration D5LR (3.6 cc/kg/hr) Paracetamol Serial CBC monitoring

19. Day 3 in the hospital (Day 4 of illness) S> Still with febrile episodes, improving appetite (+) epistaxis (known nosebleeder) (+) abdominal pain (+) vomiting episodes O> Awake, comfortable, flushed Clear breath sounds Regular cardiac rhythm (+) abdominal tenderness epigastric, no liver enlargement Full and equal pulses, warm extremities, CRT< 2 sec A> Dengue Fever with Warning Signs P> Maintain hydration (D5LR) Serial CBC monitoring Serum electrolytes Esomeprazole

20. Day 4 in the hospital (Day 5 of illness) S> Day 1 afebrile No recurrence of epistaxis (+) abdominal pain No vomiting episodes O> Awake, comfortable, flushed Clear breath sounds Regular cardiac rhythm (+) abdominal tenderness epigastric, no liver enlargement Full and equal pulses, warm extremities, CRT< 2 sec A> Dengue Fever with Warning Signs P> Increase hydration to 5- 7 cc/kg/hr Serial CBC monitoring SGOT, SGPT Esomeprazole Chest Xray FOR PICU TRANSFER

21. Day of IllnessHgbHctWBCPlatelet Count Day 2134404.4157 Day 3128383116 Day 4a135421.7110 Day 4b151453.772 Day 5a156473.770 Day 5b1584843.270 Day 5c159484.670 Day 5d15246570 Day 6a155475.294 Day 6b147434.196 Day 792272.8120 Na130 (135-145)Crea0.47 (0.52- 0.72) K4 (3.5- 5.1)SGPT228 (9-68) iCal4.64 (4.48 – 5.28)SGOT314 (5-34)

22. Chest Xray Pleural Effusion, RIGHT

23. CASE definition: WHO 2010, Interim PPS 2010 Dengue w/o warning signs

24. Problems at the PICU Hemoconcentration  Fluid support  Serial CBC monitoring Pleural effusion  Fluid titration

25. Management: Group B: (with warning signs) in hospital Treatment: Increase oral fluid intake IV fluids (0.9% saline, LR) Monitor: Temperature Pattern Fluid intake and losses Urine output Warning signs HCT, platelet, WBC

26. Indications for Hospital Discharge Absence of fever for 24 hours (without anti- fever therapy) and return of appetite Visible improvement in clinical picture Stable hematocrit 3 days after recovery from shock Platelets ³ 50,000/mm 3 No respiratory distress from pleural effusions/ascites

27. Sources WHO Dengue Guidelines on Treatment, Diagnosis, Prevention, and Control 2009 Philippine Pediatric Society interim guidelines on Dengue 2010