Case Write Up 1: Dengue Haemorrhagic Fever

Saarah Huurieyah bt Wan Rosli

10500!
"ear ! #nternal $e%icine
#D&'(#F#C)(#*' D)()
'ame : 'a+,a bt )hma% 'a-ri
)ge : 1. years ol%
Se/ : Female
Race : $alay
Religion : #slam
Registration 'o0 : )$00012.
)%%ress : 3an%an #n%ah
*ccupation : Cler4 in a clinic
$arital Status : 'ot marrie%
Date o5 a%mission : 26076007
Date o5 %ischarge : 816076007
Date o5 cler4ing : 16076007
Source o5 cler4ing : 3atient
CH#&F C*$39)#'(
Fever 5or the last . %ays be5ore a%mission: associate% ,ith vomiting an% muscle ,ea4ness
H#S(*R" *F 3R&S&'(#'; #99'&SS
Her 5ever starte% since . %ays ago an% it ,as constant0 #t is aggravate% at night ,ith
shivering0 (he 5ever is associate% ,ith hea%ache: myalgia an% muscle ,ea4ness: arthralgia:
bac4 pain: loss o5 appetite: loss o5 ,eight: rigor an% chills: retro<orbital pain: restlessness at
night: vomiting: %iarrhea: per<vaginal blee%ing: syncopal attac4: light sensitivity: sore throat:
cough an% %yspnoea: generali-e% ab%ominal pain especially at the epigastric region an% pain
in the suprapubic an% loin regions0
(he vomiting also starte% on the same %ay as the 5ever0 #t ,as also constant 5or . %ays0 #t
varies ,ith time an% came =uite 5re=uently0 (he content o5 the vomitus is ,hitish mucous an% some
5oo% an% the amount also varies0 (he vomiting is associate% ,ith shortness o5 breath an%
epigastric pain0 Ho,ever: the vomitus has no bloo% stain0
(he episo%es o5 %iarrhea starte% on the !
th
%ay o5 5ever0 (he 5re=uency is t,ice a %ay0
#t is ,atery %ar4 bro,n ant the amount also varies0 #t is not associate% ,ith any bloo% stain or
any pain0
$ean,hile: the per<vaginal blee%ing is characteri-e% as intermenstrual perio%0 (his is
because it state% on the !
th
%ay o5 the 5ever0 #t is to be an abnormal perio% because she alrea%y
ha% her perio% 5or this particular month in 7
th
o5 )ugust 0070 She never ha% any history o5
similar episo%es an% it is sai% that her menstrual cycle is regular every month0 >esi%es: her
regular menstrual cycle usually laste% only 5or 8 %ays: but this time it ,as still blee%ing even
though it ,as alrea%y on the 5
th
%ay0 During this particular episo%e: 8 pa%s ,ere 5ully soa4e%
compare% to her regular menstrual cycle ,here on only an% hal5 pa%s soa4e%0
Her 5ever is not associate% ,ith any history o5 travelling:rashes: epista/is: gum
blee%ing: pleuritic pain: haemoptysis: purulent sputum: haematuria: %ysuria: urgency:
strangury an% nec4 sti55ness0
Due to the 5ever: she ,ent to ;eneral 3ractitioner 8 times0 *n 5irst %ay o5 5ever: she
,as given antibiotics an% pain 4iller0 )s the 5ever %oesn?t subsi%e: she ,ent again to the
;eneral 3ractitioner on the 8
r%
%ay o5 5ever: an% ,as given another type o5 antibiotic yet the
5ever %i% not subsi%e0 So: she ,ent again to the ;eneral 3ractitioner on the 7
th
%ay o5 5ever
,here she %i% a bloo% test0 Without 4no,ing the bloo% test result: she ,as re5erre% to
Hospital )mpang %ue to suspecte% %engue 5ever0
S"S(&$#C R&@#&W
Cardiovascular system
She ha% %ypsnoea0 Ho,ever: there ,ere no chest pain: palpitation: orthopnea an% paro/ysmal
nocturnal %ypsnoea0
Respiratory system
She ha% sore throat an% non< pro%uctive cough0 She also ha% shortness o5 breath everytime
a5ter vomiting0 'o heamoptysis0
Gastrointestinal system
She ha% vomiting 5re=uently an% %iarrhea t,ice a %ay0 She also ha% generali-e% ab%ominal
pain especially at the epigastric region0 'o hematemesis0
Genitourinary system
She ha% suprapubic pain an% per<vaginal blee%ing Aintermenstrual blee%ingB0 >ut: there ,ere
no %ysuria: polyuria: poly%ypsia: hematuria: urgency: s,ollen an4le or urinary incontinence0
Musculoskeletal System
She complaine% o5 myalgia: muscle ,ea4ness: arthralgia: bac4pain an% rigor an% chills0
Ho,ever: there ,ere no muscle sti55ness an% abnormal gait0
Central Nervous System
She ha% hea%ache: light sensitivity: restlessness at night an% syncopal attac40 >ut: there ,ere
no tremor: loss o5 sensory: %iplopia: 5it: paralysis: speech %e5ect or bo%y incoor%inations0
3)S( $&D#C)9 H#S(*R"
(he patient ha% history o5 bronchitis in the en% o5 Cune 0070 #t ,as treate% ,ith
nebuli-er0 She also ha% gastritis ,hich ,as %iagnose% in 001 by a ;eneral 3ractitioner0 She
is compliance to her me%ication but no en%oscopy ,as %one0 She ha% no other me%ical
illness such as Diabetes $ellitus: Hypertension: #schemic Heart Disease an% asthma0
She ha% been a%mitte% t,ice in Hospital Dlang in 001 %ue to high 5ever an% the
other ,as in 005 %ue to an acci%ent0
3)S( SUR;#C)9 H#S(*R"
She ha% no past surgical history0
DRU; H#S(*R"
She ha% 3aracetamol an% some antibiotics 5or her 5ever be5ore she came to Hospital )mpang0
She is currently on a long term me%ication 5or her gastritis but she only ta4es it ,henever necessary0
(he me%ication ,ere (agamet ACimeti%ineB: $e/alone an% >uscopan0
She also ha% no 4no,n %rug allergies or other 4no,n allergies0
F)$#9" H#S(*R"
>oth her parents are still alive0 Her 5ather is !1 years ol% an% is having brain tumor0
$ean,hile her mother is 52 years ol% an% is having asthma an% a uterus problem ,hich she
coul% not name it0 She has no siblings0
S*C#)9 H#S(*R"
She is currently living ,ith 5rien%s in 3an%an #n%ah: ,hich is 4no,n to be an area o5 5ogging0
(hey live in a shop house at level 8 ,hich has no elevator an% she ha% no problem in climbing
up the stairs0 She is not marrie%0 She is a non smo4er an% %rin4er0 She also ha% no se/ual
promiscuity
*>S(&(R#CS )'D ;"')&C*9*;#C)9 H#S(*R"
Her menarche is at the age o5 1 years ol%0 Her menstrual cycle is regular ,hich
usually lasts 5or 8 %ays0
3H"S#C)9 &E)$#')(#*'
;eneral e/amination
*n inspection: patient ,as lying 5lat: loo4e% com5ortably an% ,ell0 She ,as ,ell
orientate% to time place an% person0 (here ,as a cannula on the %orsum o5 the right han%
,hich ,as connecte% to a normal saline0 Her vital signs ,ere
>loo% pressure : 11610 mmHg
3ulse rate : 1 beats per minute: regular an% normal volume
Respiratory rate : 0 breaths per minute
(emperature : 87
0
C
*

saturation : .2F on air

(here ,ere no 5acies abnormalities: muscle ,asting: scars or any other abnormalities0
(here ,ere also no signs o5 +aun%ice: pallor or cyanosis0 3atient ,as 5airly hy%rate%0
Hand
Warm: no e/cessive s,eating: capillary 5illing time ,as less than secon%s: no 5inger
clubbing: no nicotine stain: no rashes or petechiae0 Hess test ,as not %one0
Eye
'o signs o5 pallor on the con+unctiva an% no +aun%ice0
Mouth
'o central cyanosis: no gum blee%ing an% hy%ration ,as 5air0
Neck
'o lympha%enopathy: no nec4 sti55ness an% +ugular venous pressure ,as not raise%0
Lower limb
'o rashes or petechiae: no an4le e%ema0
Specific physical examination
)b%omen
#nspection: )b%omen is 5lattene%: not %isten%e% an% umbilicus ,as centrally locate% an%
inverte%0 #t moves ,ith respiration0 (here ,ere no scratch mar4s: obvious mass: %ilate% veins
or any obvious peristaltic activities0 #nguinal ori5ices ,ere intact0
3alpation: *n super5icial palpation: the ab%omen ,as so5t an% =uite ten%er on all . regions
especially at the epigastric region0 'o reboun% ten%erness: guar%ing: rigi%ity an% mass ,ere
5oun%0 *n %eep palpation: no organomegaly %etecte%0
3ercussion: )b%ominal resonance ,as presence ,ith no ascites0
)uscultation: >o,el soun% ,as hyperactive an% no renal bruit ,as hear%0
Respiratory system
#nspection: Chest move% bilaterally symmetrical ,ith respiration0 Chest ,as normal in shapeG
no 4yphosis: no scoliosis an% no lor%osis0 'o %ilate% veins an% no surgical scars0
3alpation: Chest e/pansion ,as e=ual in both si%es0 @ocal 5remitus ,ere re%uce% at the lo,er
-ones on both si%es0
3ercussion: 9ung percussion ,as %ull on the lo,er -ones o5 both si%es0 *ther parts ,ere
resonance0
)uscultation: >reath soun% ,as normal ,hich ,as vesicular breath soun%: air entry ,as
e=ual bilaterally: no ,hee-ing: no crepitation: no pleural rub an% other a%%e% soun%s0 @ocal
resonance ,as re%uce% at the lo,er -ones on both si%es0
Systemic examination
Car%iovascular system
#nspection: )pe/ beat coul% not be seen0 (here ,as also no scars: precor%ial bulge an% e/tra
pulsation observe%0
3alpation: (he ape/ beat ,as present at the 5
th
intercostal space at the mi% clavicular line ,ith
normal character0 3alpable murmur AthrillsB an% heaving ,ere absent0 'o other pulsation
5oun%0
)uscultation: (he 5irst an% secon% heart soun%s ,ere present an% normal0 (here ,as no
murmur an% a%%e% heart soun% hear%0
$usculos4eletal system
*n inspection: no s4ull: long bones an% spine %e5ormities observe%0 (here ,as also no
bone %e5ormities: ten%erness: muscle ,asting an% s,elling present at the +oints0 #n a%%ition:
there ,ere also no abnormal movements %etecte%0
Central 'ervous system
3atient ,as conscious: alert an% ,ell oriente% ,ith time: place an% person0 (he
speech: cranial nerves: sensation: motor 5unction an% re5le/es: cerebellar 5unction an% gait
,ere normal0
C)S& SU$$)R"
) 1. year<ol% $alay la%y: came in ,ith history o5 constant 5ever 5or . %ays associate%
hea%ache: myalgia: bac4pain: retro<orbital pain: ,ea4ness: restlessness: loss o5 appetite: chills
an% rigor: She also ha% vomiting: %iarrhea: pervaginal blee%ing: syncopal attac4: light
sensitivity: sore throat: cough: %yspnoea: generali-e% ab%ominal pain especially at the
epigastric region: suprapubic region pain an% loin pain0 3hysical e/amination sho,s that
there ,as slight ten%erness on all . regions o5 the ab%omen especially at the epigastric area0
9ung percussion ,as %ull at the lo,er -one on both si%es0 (he vocal 5remitus: air entry an%
vocal resonance ,ere re%uce% at the lo,er -one on both si%es0
3R*@#S#*')9 D#);'*S#S
Dengue haemorrhagic fever with gastritis.
Reasons 5or %engue haemorrhagic 5ever:
<Constant 5ever 5or . %ays
< 3resence o5 the associate% symptoms o5 a viral 5ever
< vomiting
< %iarrhea
< menorrhagia
< syncopal attac4
< light sensitivity
< sore throat: cough an% %yspnoea
< generali-e% ab%ominal pain esp0 at epigastric region
< suprapubic region pain
< loin pain
<9iving in en%emic area
<Fever ,ith menorrhagia
<Signs o5 pleural e55usion Asigni5y plasma lea4ageB
Reasons 5or gastritis:
<)b%ominal pain especially at epigastric region
<@omiting
<Diarrhea
D#FF&R&'(#)9 D#);'*S#S
1B (yphoi% 5ever
Reasons 5or:
<patient ate outsi%e 5oo%
<intermittent 5ever: hea%ache an% ab%ominal pain
<ab%ominal ten%erness
Reasons against:
<no hepatosplenomagaly: no lympha%enopathy an% no scanty maculopapular
rashes
<absence o5 bra%ycar%ia at the pea4 o5 5ever
B $alaria
Reasons 5or:
<5ever: hea%ache: vomiting an% %iarrhea
<rigors
Reasons against:
<temperature %i% not reach up to !1
0
C
<absence o5 classical tertian or =uartan 5ever
<no hepatosplenomegaly
8B Chi4ugunya
Reasons 5or:
<arthralgia: 5ever an% myalgia
Reasons against:
<rare in $alaysia but common in #n%ian *cean islan%s
!B 9eptospirosis
Reasons 5or:
<5ever: hea%ache: myalgia:
Reasons against:
< no e/posure to ,ater contaminate% ,ith animal urine
<absence o5 hepatosplenomegaly an% lympha%enopathy
#'@&S(#;)(#*'
(he investigation planne% on her as belo,:
F>C< Hb: Haematocrit: W>C: 3latelet
)>* ;roup
)ctivate% 3artial (hromboplastin (ime
Dengue #g$
3( #'R
9iver Function (est A9F(B
Renal 3o5ile
Wi%al (est
Chest E<Ray
(&S( R&SU9(S
1iB F>C< Hb: Haematocrit: W>C: 3latelet an% others A%one on 26076007B
*b+ective: (o loo4 speci5ically 5or the ,hite bloo% cells count: platelet an% haematocrit level
5or %engue in5ection0
white blood cells : 3.7 K/uL
platelet : 10 K/uL
mean platelet volume : 1201 59
re% bloo% cells : !02.
haemoglobin : 1501 g6%9
haematocrit : !. "
mean cell volume : .20. 59
mean cell haemoglobin : 80 pg
mean cell haemoglobin concentration: 880g6%9
#mpression: (he ,hite bloo% cells an% the platelet count are %ecrease%: but haematocrit level
is still in normal range0 $ean platelet volume: mean cell volume an% mean cell haemoglobin
are raise% too0 *ther rea%ings are normal0
1iiB F>C< W>C: 3latelet an% haematocrit A%one on 16076007: 76076007 an% .6076007B
*b+ective: (o loo4 speci5ically 5or the pattern o5 ,hite bloo% cells count: platelet an%
haematocrit level 5or %engue in5ection0
1607607 7607607 .607607
02:. 18:1 02:00 0.:55 11:58 00:!8 05:!. 1!:51
White bloo% cells
AD6u9B
202 70! 20. 20. 201 508 501 !01
3latelet AD6u9B 12 0 1 1 1 1 11 8
HaematocritAFB !200 !102 8101 8708 8101 850 850 8507
#mpression: (he ,hite bloo% cells count ,as in normal range throughout the 8 %ays0 (he
platelet level ,as still lo, ,hile the haematocrit level ,hich ,as normal at the
beginning starte% to %ecrease on the .
th
o5 )ugust 0070
(he results o5 Full bloo% count on 80
th
)ugust 007 an% 81
st
)ugust 007 coul% not be
obtaine%0
B )>* ;roup A%one on 16076007B
*b+ective: to %etect patient?s bloo% group in case 5or any bloo% trans5usion0
>loo% group : *
Rh ;roup : D positive
#mpression: (he patient has an * an% Rh positive bloo% group
8B )ctivate% 3artial (hromboplastin (ime A)3((B A%one on 16076007B
*b+ective: (o see coagulation time0
)3(( : 501 sec
#mpression: (he )3(( is raise%
!B Dengue #g$ A%one on 16076007B
*b+ective: (o loo4 5or any recent Dengue in5ection
Dengue #g$ : %etecte%
#mpression: Suggestive o5 a recent %engue in5ection
5B 3( #'R A%one on 16076007B
*b+ective: (o see coagulation pro5ile
3rothrombin ratio : 100 sec
#nternational 'ormalise% Ratio A#'RB : 100!
#mpression: (he prothrombin ratio is normal ,hile the #'R is %ecrease%
2B 9iver Function (est A9F(B A%one on 16076007B
*b+ective: (o see any liver impairment
(otal protein : 20.8 umol69
)lbumin : 1 g69
;lobulin : 1g6%9
)lbumin6;lobulin ratio : 1000
)l4aline phosphatise : !0 U69
)lanine (ransaminase AS;3(B : 81U69
#mpression: )lbumin is %ecrease%
1B Renal 3o5ile A%one on 16076007B
*b+ective: (o see any renal impairment
Urea : 10.0 mmol69
So%ium : 181 mmol69
3otassium : 802 mmol69
Chlori%e : 10. mmol69
Creatinine : 5 umol69
#mpression: @alues ,ithin normal range
7B Wi%al (est A%one on 16076007B
*b+ective: (o loo4 5or evi%ence o5 typhoi% 5ever
S0 3aratyphi aH 5lagellar : negative
S0 3aratyphi bH 5lagellar : negative
S0 (yphi %H 5lagellar : negative
S0 (yphi * somatic )g : negative
#mpression: (here ,as no evi%ence o5 typhoi% 5ever
.B Chest E<Ray
*b+ective: to see any lung consoli%ations an% car%iomegaly
Result : <blunt costophrenic angle
<heart ,as normal in si-e
#mpression: >lunt costophrenic angle Aa sign o5 pleural e55usionB
# ,oul% also li4e to propose some other relevant investigations such as:
1B >loo% culture: bloo% 5ilm
*b+ective: (o loo4 5or evi%ence o5 malaria
B Urine %ipstic4
*b+ective: (o loo4 5or any severe hypovolemia or any microscopic haemorrhage
8B Urine culture an% Sensitivity
*b+ective: (o loo4 5or any urinary tract in5ection
!B Sputum Culture an% Sensitivity
*b+ective: (o loo4 5or any upper respiratory in5ection
5B &n%oscopy
*b+ective: (o loo4 5or any gastric or %uo%enal ulcer0
$)');&$&'(
*n arrival at the emergency %epartment: patient ha% been given intravenous 'ormal
Saline 1000 ml68 hours an% Hantac6$a/alon0 Full bloo% count is also being trace%0 )n hour
later: patient is the me%ical ,ar%0 *n a%mission: the patient ha% been given 5 pints o5
intravenous 'ormal Saline ,hich ,as alternate% ,ith 1g DC90 She ,as also been given
me%ication such as Raniti%ine tablets 150 mg t,ice a %ay: Duphaston tablets 1 tablet once a
%ay: Raniti%ine 150 mg t,ice a %ay: Rocephine 5or 5 %ays an% Flagyl as the patient has
%iarhea an% high spi4ing 5ever0
Serial observation ,as %one on her i0e0 Full >loo% Count: Renal 3ro5ile: 9iver
Function (est: 3rothrombin (ime an% )ctivate% 3artial (hromboplastin (ime Ato loo4 5or any
blee%ing ten%encyB an% Dengue #;$0 Her 5ull bloo% count especially the haematocrit level is
monitore% every ! to 2 hours or as clinically in%icate%0 Chest /<tray ha% also been %one on
her since there ,ere signs o5 pleural e55usion on physical e/amination0
Due to her improvement: especially on the ,hite bloo% cells count: platelet level an%
she ha% alrea%y been a5ebrile: she ha% been %ischarge% on 81
st
o5 )ugust 007 an% ,as as4e%
to come again to chec4 5or her improvement0 She ,as given )mo/y Clavulinic )ci% 25mg
tablets t,ice a %ay: Ce5tria/one 1g #ntravenous in+ection once %aily: $etroni%a-ole 00mg
tablet an% $etroni%a-ole 500m6100ml in+ection every 7 hours0 )ll her me%ication is 5or 5
%ays0
D#SCUSS#*'
Dengue is the most common an% ,i%esprea% arthropo%<borne arboviral in5ection in
the ,orl% to%ay0 (he geographical sprea%: inci%ence an% severity o5 %engue 5ever ADFB an%
%engue haemorrhagic 5ever ADHFB are increasing in the )mericas: South<&ast )sia: the
&astern $e%iterranean an% the Western 3aci5ic0 Some :500 million to 8:000 million
people live in areas ,here %engue viruses can be transmitte%0 #t is estimate% that each
year 50 million in5ections occur: ,ith 500:000 cases o5 DHF an% at least 1:000 %eaths0
Dengue virus is an )rbovirus that belongs to the 5amily Flaviviridae: un%er the genus
Flavivirus0 #n the past: it ,as classi5ie% un%er the ;roup > )rboviruses0 #t is a small
envelope% virus measuring 50 to 20 nm in si-e containing a single stran%e% positive sense
R') genome0
Dengue virus is transmitte% via the bite o5 )e%es mos=uitoes in particular !ae"ypti I
!albopictus0 #n human %isease the cycle o5 transmission involves man<vector<man0
(he virus is present in bloo% in early acute phase only: generally 5or 1<5 %ays0 (he
incubation perio% varies bet,een 8 to 10 %ays ,ith an average o5 !<2 %ays0
(here are 5our serotypes o5 %engue virus AD&'<1: D&'<: D&'<8 an% D&'<!B0 (hey
areantigenically very similar to each other but %i55erent enough to elicit only transient partial
cross<protection a5ter in5ection by each one o5 them0
$ost o5 the cases are reporte% among the urban population A10 J 70FB ,ith the
highest inci%ence in the ,or4ing an% school going age group ,hich correlates ,ith the
relatively high )e%es #n%e/ in construction sites: 5actories an% schools0
$y patient: ,ho is currently living in 3an%an #n%ah: a place ,hich has a high
inci%ence o5 %engue in5ections be5ore an% is a 4no,n 5ogging area 5or 5e, times0 (hus: the
inci%ence o5 having %engue in5ection is higher0
(here are a number o5 criteria 5or the clinical %iagnosis o5 %engue in5ection0 Ho,ever:
not all the criteria nee% to be present at the same time0
10 high continuous 5ever o5 8 %ays or more
0 hea%ache: bac4ache an% retro<orbital pain
80 ab%ominal pain: vomiting: loose stools
!0 petechial haemorrhage an%6or spontaneous blee%ing
50 rash J generalise% 5lushing6maculopapular
20 hepatomegaly
10 5all in platelet count that prece%es or occurs simultaneously ,ith a rise in the
haematocrit
70 normal W>C or leu4openia ,ith relative lymphocytosis
.0 normal &SR AK0mm 5irst hourB
100 shoc4
Dengue virus in5ection may present in 5our %i55erent clinical syn%romes:
10 Un%i55erentiate% 5ever
0 Classic %engue 5ever
3. #en$ue %aemorrha$ic &e'er (#%&)
!0 Dengue Shoc4 Syn%rome LDSSM
# ,ill 5ocus the %iscussion o5 my patient on %engue haemorrhagic 5ever
Dengue Haemorrhagic Fever (DHF)
(he critical stage is reache% at the en% o5 the 5ebrile phase o5 illnessG accompanying or
shortly a5ter a rapi% %rop in temperature varying %egrees o5 circulatory %isturbances
occurs0 (his phase rarely lasts longer than !7 hours0
(he 5ollo,ing must all be present:
10 Fever: or history o5 acute 5ever: lasting <1 %ays: occasionally biphasic0
0 Haemorrhagic ten%encies: evi%ence% by at least one o5 the 5ollo,ing:
a0 a positive torni=uet test
b0 petechiae: ecchymoses: or purpura
c0 blee%ing 5rom the mucosa: gastrointestinal tract: in+ection sites or other
locations
80 (hrombocytopenia A100:0006mm8 or lessB
!0 &vi%ence o5 plasma lea4age %ue to increase% vascular permeability:
mani5este% by at least one o5 the 5ollo,ing:
a0 haemoconcentration Ae=ual to or greater than 0F above average 5or
age: se/ an% populationB
b0 a %rop in haematocrit 5ollo,ing volume replacement e=ual to or
greater than 0F o5 haematocrit at presentation0
c0 signs o5 plasma lea4age evi%ence% by pleural e55usion: ascites an%
hypoproteinemia0
*ther clinical mani5estations suggestive o5 DHF are
a0 hepatomegaly ,hich may be ten%er
b0 circulatory %isturbance
#n my patient: there ,ere 5eatures o5 %engue in5ection0 She ha% high continuous 5ever
o5 8 %ays or more: hea%ache: bac4ache an% retro<orbital pain: ab%ominal pain: vomiting:
loose stools: 5all in platelet: initially leu4openia but ,ent to the normal W>C count in later
stage0
(he reasons # %iagnose% her as having %engue haemorrhagic 5ever since there ,as
5ever ,hich laste% 5or about more than 10 %ays0 (here ,as also haemorrhagic ten%ency ,hich
,as per<vaginal blee%ing Aintermenstrual blee%ingB. She also ha% thrombocytopenia0 >esi%es:
on e/amination an% /<ray: there ,as sign o5 plasma lea4age ,hich ,as signs o5 pleural
e55usion0 *n e/amination: lung percussion ,as %ull at the lo,er -one on both si%es0 (he
vocal 5remitus: air entry an% vocal resonance ,ere re%uce% at the lo,er -one on both si%es0
$oreover: there ,as a blunt costophrenic angle on chest /<ray0
3atient must meet all the criteria be5ore being hospitalise%0 (he criteria are continuous
5ever more than 8 %ays: lethargy: restlessness: generalise% 5lushing: e/cessive tire%ness:
%ehy%rate%: ab%ominal %iscom5ort: haemorrhagic mani5estations: plasma lea4age an%
evi%ence o5 circulatory 5ailure6shoc4 such as rapi% an% ,ea4 pulse: cool: mottle% or pale s4in
or changes in mental status: restlessness an% lethargy0
#n %engue patient: ,e shoul% monitor the bloo% pressure: urine 5lo,: ,hite bloo% cells
count an% platelets0 (he treatment 5or %engue in5ection: patient shoul% be starte% on
intravenous 5lui% ,hich is 00.F so%ium chlori%e Anormal salineB L80< 50 ml64g6%ayM: DC9
supplement as re=uire%0 Ho,ever: caution is nee%e% in el%erly6car%iac %isease0 #n %iabetics
patient only normal saline must be use%0 (he haematocrit level: vital signs an% urine output
AhourlyB must be monitore% closely0
(he pleural e55usion occurs %uring the phase o5 plasma lea4age0 #t %ecreases thoracic
compliance an% 5unctional resi%ual capacity lea%ing to hypo/emia an% increase% ,or4 o5
spontaneous breathing0 (hus: massive pleural e55usions can be prevente% by +u%icious
replacement o5 intravascular volume0 $ost cases o5 blee%ing in DHF occur as a result o5
prolonge% shoc4 secon%ary to ina%e=uately correcte% plasma lea4age0 (here is a category o5
patients ,ith pre<e/isting peptic ulcers ,ho %evelop haemorrhage in the course o5 DF0
Ho,ever: there is no consensus on ho, these patients shoul% be treate%0