General Objective

To

present a case of a patient presenting

with Fever

Specific Objective
To

discuss the history and physical

examination findings relevant to the
case
To be able to formulate a clinical
impression based from the history and
PE
To
identify
possible
differential
diagnoses according to the given case
To be able to correlate case discussion
with the condition of patient

History of Present Illness

Time Frame

Pertinent (+)

Pertinent (-)

3 days PTA

Sudden onset
of documented
fever (39.3C)
Vomiting of 2-3
episodes
of
previously
ingested food

7 hours PTS

Sudden onset No epistaxic

of
abdominal No melena
pain
No LBM
(epigastric area,
non-radiating)
Still
with
vomiting
No fever

No
No
No
No

Cough
LBM
Dysphagia
Dysuria

Remarks
No consult
Paracatemol
1tbsp 3x a day

No meds taken
Sought consult
at private MD
and was
advised
admission

PAST MEDICAL HISTORY

No

previous hospitalization
No surgical history
No known allergies to food or
medications

FAMILY HISTORY

Denies Herido-Familial Disease

PERSONAL and SOCIAL

HISTORY
Mother

25 y.o. G3P3 PNCU

Father 36 y.o. MV
Delivered via CS at this institution
2nd among the 3 siblings
He lives with his parents and 2 siblings.

Immunization Status
Patient

is completely immunized
single dose BCG
3 doses of DPT, OPV and Hepa-B vaccines
single dose of measles vaccine

Feeding History

Review of System
General:

(-) weight loss, (-) lethargy, (-) easy fatigability

Skin: (-) itching
HEENT: (-) epistaxis, (-) dizziness
Cardiovascular: (-) palpitations, (-) orthopnea,(-)chest pain
Gastrointestinal: (-) constipation, (-) diarrhea, (-) blood in
the stool
Genito-urinary: (-) frequency, (-) dysuria, (-) hematuria,
Endocrine: (-) excessive sweating, (-) heat/cold intolerance
Musculoskeletal: (-) joint pain, (-) stiffness
Extremities:(-) paresthesia, (-) numbness
Neurologic: (-) seizure, (-) loss of consciousness

Physical Examination

General: awake, weak-looking, cold and clammy

VITAL SIGNS:

T: 36.3 C
Pulse Rate: 123 bpm
Respiratory Rate: 29 cycles per minute
BP: Palpatory 70

Weight: 20.5 kgs

Height: 116cm

Stunting:
Wasting
(+) Tourniquest test

Physical Examination
SKIN: (+) petechiae, ecchymoses, no wounds
HEENT:

Head: Normocephalic; Hair is black, has equal

distribution and
average texture; No lumps; No
tenderness
Eyes: pink palpebral conjunctiva; Anicteric sclera;
pupils
equally reactive to light 2-3mm
Ears: No discharges; Acuity is good to speaking voice
Nose: Pink Nasal Mucosa, No discharges, No
tenderness
Mouth and throat: (-) gum swelling or bleeding, (-)
tonsillar enlargement, pink buccal mucosa
NECK: No visible neck mass; No thyroid enlargement, No
cervical lymphadenopathies

Physical Examination
CHEST

& LUNGS
Equal chest expansion, No retractions; No lesions, No
tenderness; No mass; Clear breath sounds
CARDIOVASCULAR

Adynamic precordium; apical beat at the 5th left I ntercostal

space, MCL; RRR; No murmurs
ABDOMEN

Flat; Normoactive bowel sounds; Tympanitic; No

hepatosplenomegaly; Soft; Tenderness on Right

Upper Quadrnt

EXTREMITIES

Cold and clammy, No edema, No varicosities, poor

brachial and radial pulses; CRT 2sec.

and thready

Clinical Impression

Dengue

Shock Syndrome

Basis
History
Sudden

onset of high grade fever

Vomiting
Abdominal pain
3rd day : Afebrile
PE
Bp: palpatory 70
PR: 123
T: 36.3 C
Cold and clammy skin
(+) tenderness RUQ
(+) poor and thready pulses
(+) tourniquet test

Differential Diagnoses
Ruled- In
1. Acute
TonsilloPharyngitis

(+) Fever

2. Urinary Tract
Infection

(+) Fever
(+) vomiting
(+) abdominal pain

3. Typhoid fever

(+) Fever

4. Malaria

(+) Fever

Ruled- Out
(-) Dysphagia
(-) swollen tonsils
(-) dysuria

Course in the ward

March 25, 2015 (On admission) 4:40PM
S
3rd Day of Illness
1st Day Afebrile
(+) Abdominal pain
(+) vomiting
Afebril: 36.3

VS:
Bp: Palpatory 70
T: 36.3C
P: 123 bpm
R: 29cpm
O2sat: 96%
Awake, weak-looking,
cold and clammy skin
AS, PPC, (+) sunken
eyeballs
ECE, CBS
AP. Tachycardic, (-)
murmur
Flat, NABS, (+)
tenderness RUQ
Poor and thready
pulses
(+) Tourniquet test

Dengue Shock
Syndrome

P
Admit to W8-ICU
DAT except dark
colored food
IVF: PLR1L to run @
36gtts/min x 2hrs
then refer for RA
Start another line
with PNSS 1L to run
@ 400cc FDx 2 then
refer for RA
Labs:
-CXR APL
- Cbc, plt, BT
-serial hct/plt q6
-dengue NS1
Meds:
Paracetamol 200mg
IVT PRN q 4 for
T>38
Ranitidine 14mg IVT
now then q8
Monitor VS and BP
q1
Monitor I and O q

Course in the ward

March 25, 2015 (On admission) 6:40PM
S
(+) Abdominal pain
Afebril: 36.5C

VS:
Bp: 110/80
T: 36.5C
P: 120 bpm
R: 25cpm
O2sat: 96%
Awake, weak-looking,
AS, PPC, (+) sunken
eyeballs
ECE, CBS
AP. Tachycardic, (-)
murmur
Flat, NABS, (+)
tenderness RUQ
Good pulses
TFI: 5cc/kg

Dengue Shock
Syndrome

Hold IVF PNSS, then

PLR 1L to run @ 26
gts/min in 4 hours
then refer for RA

Course in the ward

March 25, 2015. 10PM
S
(+) Abdominal pain
Afebril: 36.5C

VS:
Bp: 100/70
T: 36.5C
P: 111 bpm
R: 25cpm
O2sat: 96%
Awake, NIRD
AS, PPC, (-) sunken
eyeballs
ECE, CBS
AP. Tachycardic, (-)
murmur
Flat, NABS, (+)
tenderness RUQ
Good pulses
Hct: 0.50
Plt: 20
BT: B +
TFI: 5cc/kg

Dengue Shock
Syndrome

Cont IVF with PLR

1L to run @
25gtts/min in 4
hours then refer fro
RA
Cont meds
Ff up labs
Refer accordingly

Course in the ward

March 26, 2015 @ 4AM
S
4th Day of Illness
2nd day Afebrile
(+) Abdominal pain
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 90/60
T: 36.5C
P: 11 bpm
R: 22cpm
O2sat: 96%

Dengue Shock
Syndrome

TFI: 5cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, tachycardic
Globular, NABS, (+)
RUQ tendrness
Good pulses

Cont IVF with PLR

1L to run @
25gtts/min in 4
hours then refer fro
RA
Cont serial hct/plt
q^
Refer accordingly

Course in the ward

March 26, 2015 @ 6AM
S
(+) Abdominal pain
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 90/60
T: 37C
P: 100 bpm
R: 28cpm
O2sat: 99%
TFI: 5cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO: 100ml
Hct: 0.50
Plt: 18

Dengue Shock
Syndrome

IVF PLR 1L to run @

36gtts/min in 2
hours then refer for
RA
Cont meds
Cont VS and BP q 1
Cont serial hct/ plt
q6
Cont I and O q shift
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 26, 2015 @ 9:15 AM
S
(+) Abdominal pain
(+) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 90/60
T: 36.9C
P: 115 bpm
R: 23cpm
O2sat: 99%
TFI: 7cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct: 0.52
Plt: 20

Dengue Shock
Syndrome

IVF PLR 1L to run @

36gtts/min in 2
hours then refer for
RA
Cont meds
Cont VS and BP q 1
Cont serial hct/ plt
q6
Cont I and O q shift
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 26, 2015 (2:10PM)
S
(+) Abdominal pain
(+) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 110/80
T: 36.5C
P: 100 bpm
R: 27 cpm
O2sat: 99%
TFI: 7cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct: 0.55
Plt: 20

Dengue Shock
Syndrome

IVF PLR 1L to run @

36gtts/min in 2
hours then refer for
RA
Cont meds
Cont VS and BP q 1
Cont serial hct/ plt
q6
Cont I and O q shift
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 26, 2015 (6 PM)
S
(+) Abdominal pain
(+) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 190/60
T: 36.5C
P: 106 bpm
R: 24 cpm
O2sat: 99%

Dengue Shock
Syndrome

TFI: 7cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct: 0. 55
Plt: 20

IVF PLR 1L to run @

205 cc in 1 hour
den regulate to
36gtts/min in 2
hours then refer for
RA
Start omeprazole
10mg IVTT now the
q12
Cont VS and BP q 1
Cont serial hct/ plt
q6
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 26, 2015 (9 PM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.5

VS:
Bp: 90/60
T: 36.5C
P: 100 bpm
R: 25 cpm
O2sat: 99%
TFI: 7cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome

IVF PLR 1L to run @

36gtts/min in 2
hours then refer for
RA
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 27, 2015 (12:30 AM)
S
5th day of Illness
3rd day Afebrile
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.3

VS:
Bp: 100/60
T: 36.3C
P: 100 bpm
R: 25 cpm
O2sat: 99%
TFI: 5cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct: 0.41
Plt: 13

Dengue Shock
Syndrome

IVF PLR 1L to run @

26gtts/min in 6
hours then refer for
RA
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 27, 2015 (6 AM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.3

VS:
Bp: 90/60
T: 36.3C
P: 100 bpm
R: 25 cpm
O2sat: 99%
TFI: 3cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome

IVF PLR 1L to run @

16gtts/min in 4
hours then refer for
RA
Cont meds
Cont VS and BP q 1
Cont serial hct/ plt
q6
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 27, 2015 (11:20 AM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.7

VS:
Bp: 100/70
T: 36.3C
P: 105 bpm
R: 23 cpm
O2sat: 99%
TFI: 3cc/kg
Awake NIRD
AS PPC
ECE, CBS
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome

IVF PLR 1L to run @

16gtts/min in 4
hours then refer for
RA
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 27, 2015 (11:20 PM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.7

VS:
Bp: 100/70
T: 36.3C
P: 110 bpm
R: 47 cpm
O2sat: 99%
TFI: 2cc/kg
Awake NIRD
AS PPC
ECE, dec breath
sounds Bibasal
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome T/C pleural
effusion

Terminate PNSS line

and place to
heplock
IVF PLR 1L to run @
10gtts/min in 4
hours then refer for
RA
CXR PAL
Hook o 02 at 3LPM
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 27, 2015 (511:50PM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.8

VS:
Bp: 100/70
T: 36.8C
P: 70 bpm
R: 28 cpm
O2sat: 99%
TFI: 2cc/kg
Awake NIRD
AS PPC
ECE, dec breath
sounds Bibasal
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome; pleural
effusion

Monitor prsent IVF

to run @ 10gtts/min
in 4 hours then
refer for RA
Refer for bleeding,
narrow pulse
pressure and
hypotension

Course in the ward

March 28, 2015 (6:15AM)
S
(+) Abdominal pain
(-) headache
(-) vomiting
(-)bleeding episodes
(-)DOB
Afebril: 36.7

VS:
Bp: 100/70
T: 36.8C
P: 102 bpm
R: 26 cpm
O2sat: 99%
TFI: 2cc/kg
Awake NIRD
AS PPC
ECE, dec breath
sounds Bibasal
AP, NRRR, (-) murmur
Globular, NABS, (+)
RUQ tenderness
Good pulses
UO:
Hct:
Plt:

Dengue Shock
Syndrome; pleural
effusion

Monitor prsent IVF

to run @ 10gtts/min
in 4 hours then
refer for RA
Refer for bleeding,
narrow pulse
pressure and
hypotension

CASE DISCUSSION
Dengue is the most rapidly spreading
mosquito-borne viral disease in the world
Dengue virus (DEN) is a small singlestranded RNA virus comprising four distinct
serotypes
(DEN-1 to -4).
Belongs to Flaviviridae family

CASE DISCUSSION
Transmission of Dengue virus is primarily
transmitted
by
Aedes
mosquitoes,
particularly Aedes Aegypti. Other Aedes
species that transmit the disease include:
1.
2.
3.

Aedes Albopictus,
Aedes Polynesiensis
Aedes Scutellaris.

Mosquito Life cycle

The Host
Humans

are the primary host of the

virus
Incubation period: 4-10 days

Case Classification and level of

severity
1.

Dengue without warning signs

Probable dengue
Live in/travel to dengue endemic area. Fever and 2 of the following criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leucopenia
Any warning sign
Laboratory confirmed
dengue
(important when no sign of plasma
leakage)

The course of dengue

illness

Febrile Phase
The

acute febrile phase usually lasts 2-7 days

Mild hemorrhagic manifestations like petechiae and
mucosal membrane bleeding (e.g., nose and gums)
The earliest abnormality in the full blood
count is a progressive decrease in total white

cell count
CLINICAL SIGNS AND SYMPTOMS

Fever, Headache, Body malaise, Myalgia, Arthralgia, Retro-orbital

pain, Anorexia, Nausea, Vomiting, Diarrhea, Flushed skin, Rash
(petechial, Hermanns sign)
AND
Laboratory test, at least CBC (leucopenia with
or without thrombocytopenia) and/or dengue
NS1 antigen test or dengue IgM antibody test
(optional)

Critical Phase
Defervescence

occurs on day 3-7 of illness

Around the time of defervescence, patients can
either improve or deteriorate.
Warning signs are the result of a significant
increase in capillary fragility. This marks the
beginning of the critical phase.
The period of clinically significant plasma leakage
usually lasts 24 to 48 hours.

Recovery Phase
A

gradual re-absorption of extravasated fluid

from the intravascular to the extravascular space
(e.g., pleural effusion, ascites) by way of the
lymphatics will take place in the next 48-72
hours.

Case Classification and Levels of

Severity
Dengue without Warning Signs
Probable dengue:
Lives in or travels to dengue-endemic area, with fever, plus any two of the following:
Headache
Body malaise
Myalgia
Arthralgia
Retro-orbital pain
Anorexia
Nausea
Vomiting
Diarrhea
Flushed skin
Rash (petechial, Hermanns sign)
AND
Laboratory test, at least CBC (leucopenia with or
without thrombocytopenia) and/or dengue NS1 antigen
test or dengue IgM antibody test (optional)
Confirmed dengue:
Viral culture isolation
PCR

Case Classification and Levels of

Severity
Dengue with Warning Signs
Probable dengue:
Lives in or travels to dengue-endemic area, with fever
lasting for 2-7 days, plus any of the following:
Abdominal pain or tenderness
Persistent vomiting
Clinical signs of fluid accumulation
Mucosal bleeding
Lethargy, restlessness
Liver enlargement
Laboratory: increase in Hct and/or decreasing platelet
count

Confirmed dengue:
Viral culture isolation
PCR

Case Classification and Levels of

Severity
Severe Dengue
Lives in or travels to a dengue-endemic area with fever
of 2-7 days and any of the above clinical manifestations
for dengue with or without warning signs, plus any of
the following:
Severe plasma leakage, leading to:
Shock
Fluid accumulation with respiratory distress
Severe bleeding
Severe organ impairment
- Liver: AST or ALT >1000
- CNS: e.g., seizures, impaired consciousness
- Heart: e.g., myocarditis
- Kidneys e.g., renal failure

PARACLINICALS
CBC,

platelet, blood typing

Serial hematocrit and platelet
ALT, AST
Dengue NS1 (1st-5th day of Illness)
Dengue duo (5th day to 6 months of
illness)

Management

GROUP A Patients who may be sent home

Action Plan
Oral rehydration solution (ORS) should be given based on weight,
using currently recommended ORS:
Reduce osmolarity of ORS containing sodium 45 to 60 mmol/liter
Sports drinks should NOT be given due to its high osmolarity
which may cause more danger to the patient.
Calculation of Oral Rehydration Fluids Using Weight (Ludan
Method)
Body weight (kg) ORS to be given
>3-10 100 mL/kg/day
>10-20 75 mL/kg/day
>20-30 50-60 mL/kg/day
>30-60 40-50 mL/kg/day

Management
GROUP

B Patients who should be referred for

inhospital management

a. Dengue without Warning Signs

Encourage

oral fluids. If not tolerated, start

intravenous fluid therapy of 0.9% NaCl (saline) or
Ringers Lactate with or without dextrose at
maintenance rate

Management

Management
f

the patient shows signs of mild dehydration but

is NOT in shock, the volume needed for mild
dehydration is added to the maintenance fluids
to determine the total fluid requirement (TFR).
Periodic assessment is needed
Clinical parameters should be monitored closely
and correlated with the hematocrit.
The IVF rate may be decreased anytime as
necessary based on clinical assessment.
If the patient shows signs of deterioration see
Management for Compensated or Hypotensive
Shock, whichever is applicable.

Management
b. Dengue with Warning Signs
1. Obtain a reference hematocrit before fluid therapy
2. Give only isotonic solutions such as 0.9% NaCl (saline),
Ringers Lactate, Hartmanns solution.
Start

with 5-7 mL/kg/hour for 1-2 hours, then

reduce to 3-5 mL/kg/hr for 2-4 hours, and then
reduce to 2-3 mL/kg/hr or less according to clinical response

3. Reassess the clinical status and repeat the hematocrit

4. If the hematocrit remains the same or rises only minimally,
continue with the same rate (2-3 mL/kg/hr) for
another 2-4 hours.
5. If there are worsening of vital signs and rapidly rising
hematocrit, increase the rate to 5-10 mL/kg/hour for 1-2 hours

Management
b. Dengue with Warning Signs
6. Reassess the clinical status, repeat hematocrit and review
fluid infusion rates accordingly
7. Give the minimum intravenous fluid volume required to
maintain good perfusion and urine output of about 0.5
mL/kg/hr. Intravenous fluids are usually needed
for only 24 to 48 hours.
8. Reduce intravenous fluids gradually when the rate
of plasma leakage decreases towards the end of the
critical phase. This is indicated by:
Urine output and/or oral fluid intake is/are adequate,
or
Hematocrit decreases below the baseline value in
a stable patient