GP ON DU T Y : DR .

T I K A
R E S I DE NT ON DU T Y : DR . E VI R OS S A
CO- A S S ON DU T Y :
L E ONY NE R R Y S . T A MB U NAN
R A DE N A NNI S A CI T R A P E R MADI
DUTY REPORT WARD UNIT
22
ND
OCTOBER , 2014
PATIENTS RECAP
3
rd
floor
Nasopharingeal Carcinoma

4
th
floor
POST SYNCOPE
IBD
Anemia, with susp. Pneumonia
SIDA


6
th
floor
DHF

PATIENTS IDENTITY
Name : Mr. J
DOB : 17 Feb 1989
Age : 25 y.o
Gender : Male
Occupation : Unemployed
Address : Manggarai Jakbar
Medical Record no. : 225164
Date of admission : 22
nd
October , 2014 at 01.00
WIB
ANAMNESIS
Chief Complain:
Fever since 4 days before admission

History of present illness:
Patient came with fever since 4 days before admission.
FEVER
all day
Relieved by paracetamol on day 2 but not to the baseline
temperature
No fever prior to admission (day 4)

Associated with diarrhea, 7 times a day on the 4
th
day > the
stool is watery, no blood, no mucus, no pus, no waste, not oily
nor smelly with yellow brownish color.
Nausea and Vomiting (+), 3 times a day, food containing vomit


Autoanamnesa at 01.00 WIB on 22
nd
October 2014
Patient denied
any bleeding from gum, nose, bloody stool or urine
Headache
Pain in the back of the eyes
Rash
Abdominal pain
Muscle ache


This is the first time patient experiences these
complaints.




History of past illness:
Denies any history of hypertension, DM, heart problems, stroke,
asthma, hepatitis, and allergies.


Family History:
No known family member or relatives have the same
complaints

History of Socio-habits:
Smoking 1 pack/day since 3yr before admission
No history of drinking alcohol
No one in the relatives or family or collegue have the same
complaints

History of medications:
Paracetamol 3 x 500 mg for 3 days




PHYSICIAL EXAMINATION
GENERAL EXAMINATION
General condition :
Consciousness : compos mentis
Blood pressure : 120/80 mmHg
HR : 88x/min, regular, full
RR : 18x/min, thoracoabdomino, kussmaul (-)
Body temperature : 34 C
Body Weight : 96 kg
Body Height : 170 cm
IMT : 33,2 (obese)
PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION
Head: normocephal
Hair: normal distribution, black color
Face: symmetrical, deformity (-)
Eye: pale conjunctiva -/-, icteric conjunctiva -/-, -
ENT: normotia, normosepta, rhinorrhea (-), otorrhea (-), blood(-),
hyperemic pharynx (-), calm T1-T1
Mouth: mucous is normal
Neck: Lymphadenopathy (-)
Skin: warm, pale (-)

PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION

Thorax
Pulmonary Examination
Inspection : normochest, symmetrical chest movement on static
and dynamic. ICS retraction (-), no rash
Palpation : symmetrical chest expansion and tactile fremitus, (-)
mass, (-) tenderness
Percussion : sonor at both lung field
Auscultation : bronchovesicular +/+, rhonchi -/-, wheezing -/-

PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION

Thorax
Cardiac Examination
Inspection : invisible ictus cordis
Palpation : impalpable ictus cordis
Percussion
Right heart border : Right parasternal line
Left heart border : Left midclavicular line
Heart waist : ICS III left parasternal line
Auscultation : S1/S2 regular, gallop (-), murmur (-)

PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION

Abdominal examination
Inspection : not distended, mass(-)
Auscultation : normal bowel sound ; 8x/min
Palpation : tenderness and rebound tenderness alll over
regio (-),hepatomegaly and splenomegaly (-)
Percussion : timpani
Special examination : shifting dullness (-), fluid wave (-)
Rumple Leed : +
Extremities: warm skin, pale (-) CRT <2 sec , rash (-)


RUMPLE LEED
RUMPLE LEED
WORK UP
Jenis Pemeriksaan Saat Ini Nilai Rujukan
HEMATOLOGY
Hemoglobin 20.5* 13-18 mg/dL
Hematocrit 58* 40-52%
Leukocyte 5700 4800 10800 /uL
Trombocyte 80.000* 150000 400000 /uL
Jenis Pemeriksaan Nilai Saat Ini Nilai Rujukan
IMMUNOSEROLOGY
Salmonella Thypii O 1/80 negative
Salmonella Para
Thypii AO
negative negative
Salmonella Para
Thypii BO
negative

negative
Salmonella Para
Thypii CO
negative

negative
l
Salmonella Thypii H 1/80 negative
Salmonella Para
Thyoii AH
negative

negative
Salmonella Para
Thypii BH

negative

negative

Salmonella Para
Thypii CH
1/160 negative
RESUME
Male, 25 y.o, came with fever since 4 days
before admission, with no rash, any
bleeding from gum, nose, bloody stool or
urine, headache , retroorbital pain, rash,
abdominal pain, myalgia, shortness of
breath. On physical examination, vital signs
are normal, percussion on both lung fields
are sonor, there is no sign of peural
efussioin nor asictes and the positive
rumple leed test. On the work up lab,
patient has hemoconcentration and
trombocytopenia.

LIST OF PROBLEMS
1. Acute Fever
2. Nausea and vomiting
3. Diarrhea
4. Obese
5. Hemoconcentration
6. Thrombocytopenia



DIAGNOSIS
Working diagnosis
Dengue Hemorrhagic Fever gr I


DENGUE HEMORRHAGIC FEVER
Complete 4 of the following criteria :
Fever or history of fever lasting 27 days, occasionally biphasic
A haemorrhagic tendency shown by at least one of the
following: a positive tourniquet test*; petechiae, ecchymoses
or purpura; bleeding from the mucosa, gastro-intestinal tract,
injection sites or other locations; haematemesis or melaena
Thrombocytopenia [(100,000 cells/mm3 (1006109/L)]{
Evidence of plasma leakage due to increased vascular
permeability shown by: an increase in the haematocrit >20%
above average for age, sex and population; a decrease in
the haematocrit after intervention >20% of baseline; signs of
plasma leakage such as pleural effusion, ascites or
hypoproteinaemia

PLANNING
DIAGNOSTIC PLAN MANAGEMENT PLAN
CBC Non Pharmacology :
- Bed rest
- Soft Dietary
- Urine catheter placement


Serology Test (IgM, IgG) Pharmacology :
- Fluid Therapy RL

NS-1 Antigen - Ondancentron 3 x 4 mg IV
SGOT/SGPT - Paracetamol 3 x 500 mg PO
Radiology > X-ray Thorax AP,
Lateral Decubitus
FLUID REPLACEMENT
LOADING DOSE
5-7 ml/kg/hr 1-2 hr
500 cc in 1-2hr

3-5 ml/kg/hr in 2-4 hr
300 cc in 2-4hr

2-3 ml/kg/hr or less according to
clinical response
200 cc/hr

Monitor VS (4 hourly
urine output(4-6hrly)
Hct(before & after fluid
replacement then 6-12hrly)
BG




MAINTANANCE
1500 + 20 (BB-20)
1500 + 20 (96-20)
3020 ml/24 hr

PROGNOSIS
Quo ad Vitam: bonam
Quo ad functionam: bonam
Quo ad sanactionam: bonam
REFERENCES
DENGUE
EPIDEMIOLOGY
Most important arthropod-borne viral diseases in
terms of human morbidity and mortality.
Important public health problem.
Tropical & subtropical regions around the world
urban and semi urban areas
VIROLOGY
Dengue virus
mosquito-borne flavivirus.
Transmitted by
Aedes aegypti
Aedes albopictus.
DEN-1, 2, 3 and 4.
VIROLOGY
Each episode of infection
a life-long protective immunity to the homologous serotype
partial & transient protection against subsequent infection
by the other three serotypes.
Secondary infection is a DHF major risk factor
VIROLOGY
Other important contributing factors for DHF are
viral virulence
host genetic background
T-cell activation
viral load
auto-antibodies

SPECTRUM OF INFECTION
The incubation period is 4-7 days (range 3-14)
Asymptomatic a spectrum of illness
Undifferentiated mild febrile illness severe disease
(plasma leakage (-/+_) & organ impairment
Systemic & dynamic disease with
Clinical
Haematological
Serological
profiles changing from day to day.
PATHOPHYSIOLOGY
Increased vascular permeability is the primary
pathophysiological abnormality in DHF/ DSS.
Increased vascular permeability leads to plasma
leakage and results in hypovolaemia/ shock.
PATHOPHYSIOLOGY
The pathogenetic mechanism for the increased
vascular permeability (?)
Destructive vascular lesions (-)
post-mortem (microscopically),
perivascular oedema
loss of integrity of endothelial junctions
endothelial dysfunction
AbN immune response
production of cytokines or chemokines,
activation of T-lymphocytes
disturbances of haemostatic system
C3a, C5a, TNF-, IL-2, 6 & 10, IFN-, histamine
TOURNIQUET TEST
In DHF grade 1 (+) tourniquet test serves as the
only indicator of haemorrhagic tendency.
Sensitivity 0% to 57% (phase of illness)
5-21% false positive
How to perform tourniquet test
Inflate the blood pressure cuff on the upper arm to
a point midway between the systolic and diastolic
pressures for 5 minutes.
A positive test is when 20 or more petechiae per
2.5 cm (1 inch) square are observed.
The 1997 WHO classification of dengue virus infection.
DF
Probable
An acute febrile illness with two or more of the
following manifestations: headache, retro-orbital
pain, myalgia, arthralgia, rash, haemorrhagic
manifestations and leucopenia
And
Supportive serology (a reciprocal
haemagglutination-inhibition antibody titre >1280, a
comparable IgG enzyme-linked immunosorbent
assay (ELISA, see chapter 455) titre or a positive IgM
antibody test on a late acute or convalescent-phase
serum specimen)
Or
Occurrence at the same location and time as other
DF cases
Confirmed
A case confirmed by one of the following laboratory
criteria:
Isolation of the dengue virus from serum/autopsy samples
At least a four-fold change in reciprocal IgG/IgM titres to one
or more dengue virus antigens in paired samples
Demonstration of dengue virus antigen in autopsy tissue, serum
or cerebrospinal fluid samples by immunohistochemistry,
immunofluorescence or ELISA
Detection of dengue virus genomic sequences in autopsy
tissue serum or cerebrospinal fluid samples by polymerase
chain reaction (PCR)
Reportable
Any probable or confirmed case should be reported

DHF
For a diagnosis of DHF, a case must meet all four of the
following criteria:
Fever or history of fever lasting 27 days, occasionally
biphasic
A haemorrhagic tendency shown by at least one of the
following: a positive tourniquet test*; petechiae,
ecchymoses or purpura; bleeding from the mucosa,
gastro-intestinal tract, injection sites or other locations;
haematemesis or melaena
Thrombocytopenia [(100,000 cells/mm3 (1006109/L)]{
Evidence of plasma leakage due to increased vascular
permeability shown by: an increase in the haematocrit
>20% above average for age, sex and population; a
decrease in the haematocrit after intervention >20% of
baseline; signs of plasma leakage such as pleural
effusion, ascites or hypoproteinaemia
DSS

For a case of DSS, all four criteria for DHF must be
met, in addition to evidence of circulatory failure
manifested by:
Rapid and weak pulse
And
Narrow pulse pressure (,20 mmHg or 2.7 kPa)
or manifested by
Hypotension for age
And
Cold, clammy skin and restlessness
World Health Organization. Dengue
Guidelines for Diagnosis, Treatment,
Prevention and Control
New Edition 2009. WHO: Geneva; 2009
The following manifestations are important in
dengue infection but are often under- recognised
or misdiagnosed
Acute abdomen :
Hepatitis and liver failure :
Neurological manifestation :
Haemophagocytic syndrome

DISEASE MONITORING LABORATORY
TESTS
Full Blood Count (FBC)
1. White cell count (WCC) :
2. Haematocrit (HCT) :
3. Thrombocytopaenia :
Liver Function Test
DIAGNOSTIC TESTS
DENGUE SEROLOGY TESTS
Haemagglutination Inhibition Test
Dengue IgM test
Indirect IgG ELISA test
Cross-react with:
other flavivirus Japanese Encephalitis
non-flavivirus malaria, leptospirosis, toxoplasmosis, syphilis
connective tissue diseases rheumatoid arthritis
VIRUS ISOLATION
POLYMERASE CHAIN REACTION (PCR)
NON-STRUCTURAL PROTEIN-1 (NS1 Antigen)
Clinical and Laboratory Criteria for Patients Who Can be Treated at
Home
The following should be taken into consideration
before discharging a patient.
Afebrile for 48 hours
Improved general condition
Improved appetite
Stable haematocrit
Rising platelet count
No dyspnoea or respiratory distress from pleural effusion
or ascites
Resolved bleeding episodes
Resolution/recovery of organ dysfunction
THANK YOU