PEDIATRICS WARD

REPORT

KUMARASAMY
TUPAC
VEA
 GENERAL DATA
• Name: E.M.
• Age: 17 years old
• Address: Gattaran, Cagayan
• Gender: Male
• Nationality: Filipino
• Religion: Roman Catholic
• Informant: Patient (95% reliable) and mother (80% reliable)
• Date of Admission: January 19, 2019 at 5:00 pm
• Date of Interview: January 17, 2018 at 1:00 pm
CHIEF COMPLAINT

Fever
 HISTORY OF PRESENT ILLNESS
7 days prior to admission, the patient had sudden onset of
high grade fever (39 degree Celsius) and vomiting of food
contents. He also experienced loss of appetite, pain in the
joints, weakness, and headache. The patient took paracetamol
and relief was noted.

5 days prior to admission, persistence of above symptoms

and rashes was noted this prompted the patient and mother
to sought consultation in Calaogan Dakkel Emergency
Hospital. CBC was done revealing platelet result of 300,000
and was prescribed syndex and multivitamins. Patient was
sent home.
 HISTORY OF PRESENT ILLNESS

3 days prior to admission, No improvement of the

above signs and symptoms patient and mother sought
medical consultation on the same medical institution. CBC
was done with a result of 108,000. Patient was advised to
comeback again tomorrow for monitoring.
Few hours prior to admission, Patient’s platelet
revealed 70,000. This prompted immediately referral to
CVMC. Upon arrival at CVMC platelet level was checked with
59,000 hence admission.
 PAST MEDICAL HISTORY
• No previous hospitalization
• No known allergies to food, pollen or drugs.
• No history of accident/fall and surgery.
 MATERNAL HISTORY
The patient was born to a 54 years old, G7P7
(7007) mother. No comorbid conditions noted. No
exposure to radiation, smoking, alcohol intake, and
illicit drug.
 BIRTH & NEONATAL HISTORY
The patient was born at term pregnancy via
normal vaginal delivery at home. Skilled birth
attendants assisted the delivery. He is 4th child out of 7
children.
 NUTRITIONAL HISTORY
The patient was breastfed until 1 years old.
Introduced solid foods at 5 months like lugaw with egg.
He prefer foods rich in meat and vegetables.
 GROWTH AND DEVELOPMENT
He was able to sit alone at 8 months, walk alone
at 13 months, and spoke his first word “Mama” at 13
months.
 IMMUNIZATION

VACCINE 1ST DOSE 2ND DOSE 3RD DOSE

BCG ̷
Hepatitis B ̷ ̷ ̷
DPT ̷ ̷ ̷
OPV ̷ ̷ ̷
Hib ̷ ̷ ̷
Measles ̷
MMR ̷
 FAMILY HISTORY
No family history of hypertension, tuberculosis,
asthma and cancer
 SOCIOECONOMIC AND ENVIRONMENTAL HISTORY
• Living circumstances: They live in a cemented, bungalow
type house with 2 bedrooms. The patient lives with her
grandparents and younger sibling.
• Economic Circumstance: The mother works as a vendor in
the public market and father works as a farmer.
• Environmental Circumstance: According to his mother,
there were breeding sites for mosquitoes in their
surroundings such as stagnant water and ornamental plants
as house decorations. She also stated that their were
notable dengue cases around the area.
• Social: The patient is a grade 11 student of Calaoagan
Dakkel national high school taking ABM track.
 CONSTITUTIONAL Weight of the child during admission is 50kgs
which is normal in weight; febrile

INTEGUMENTARY (+) pruritus; (-) jaundice

HEENT Head: (+)headache, (-)seizure

Eyes: No eye pain and redness

Ears: No earache and abnormal discharge

Nose: No nasal discharges and nosebleeds

Throat: No history of tonsillitis

REVIEW OF
SYSTEMS NECK

CARDIOVASCULAR
No dysphagia

No history of rheumatic fever or any heart

disease;

RESPIRATORY (-) productive cough; (-) hemoptysis; (-) dyspnea

GASTROINTESTINAL (+) vomiting,(+) abdominal pain, (-) diarrhea, (-)

constipation

GENITOURINARY (-) hematuria, (-) oliguria, (-) dysuria

HEMATOLOGIC (-)epistaxis,(-) gumbleeding, (-) easy bruising

MUSCULOSKELETAL (+) myalgia, (+) arthalgia

ENDOCRINE (+) loss of appetite, (-)weight loss, (+) fever

 GENERAL: The patient looks weak but is conscious, cooperative in physical
assessment, afebrile, and not in cardiorespiratory distress. He is
hooked on IV Fluid of D5LRS at right arm.

HR:
72 bpm
T:
36.8 °C
RR:
17 cpm
O2 Sat:
99%
BP:
110/90mmHg
Height:
5’2 inch

SKIN Warm to touch with good skin tugor

PHYSICAL EXAM
 Physical exam

HEAD,EYES,EARS, Head: Minimal quantity of hair; No dandruff and scalp lesions

NOSE,THROAT Eyes: Pink conjunctive; Good visual acuity; Intact extraocular
muscle movements
Ears: No malodorous discharge
Nose: Nasal septum in midline; no nasal discharges
Throat: Lips and buccal mucosa are moist; tonsils are not
inflamed

NECK No palpable cervical lymph node; No nuchal rigidity

THORAX Symmetrical chest expansion; Resonant in all lung fields upon
percussion; with normal bronchovesicular sounds; no
adventitious sound
 Physical exam

HEART NO HEAVES AND THRILLS; NORMAL HEART SOUNDS; NO

MURMUR; PMI IS AT 5 TH ICS

ABDOMEN Soft, flat, no visible pulsations, 10 bowel sounds per minute

(normoactive)

LOWER EXTREMITIES No edema; no deformities; no clubbing and cyanosis; able to walk

without difficulty

NEUROLOGIC CN 2: pupil 2-3 mm, reactive to light and accomodation

CN 3,4,6: intact EOM movement

CN 7: no facial asymmetry

CN 8: able to respond to sound

CN 12: tongue midline

 IMPRESSION

DENGUE WITH WARNING SIGNS

 DIFFERENTIAL DIAGNOSIS
1. MALARIA
RULE IN RULE OUT

Fever (-) jaundice

Chills (+) rash
Malaise
Headache
Loss of appetite
Abdominal pain
 DIFFERENTIAL DIAGNOSIS
2. GASTROENTERITIS
RULE IN RULE OUT

Abdominal pain (+)rash

Fever (+) fever
Loose watery stools (+) joint pains
 CASE DISCUSSION
• Dengue is the fastest spreading vector-borne disease in
the world endemic in 100 countries·
• Dengue virus has four serotypes (DENV1, DENV2,
DENV3 and DENV4)
• First infection with one of the four serotypes usually is
non-severe or asymptomatic, while second infection with
one of other serotypes may cause severe dengue.
• Dengue has no treatment but the disease can be early
managed.
• The five year average cases of dengue is 185,008; five
year average deaths is 732; and five year average Case
Fatality Rate is 0.39 (2012-2016 data).
• Dengue virus is
transmitted by day
biting Aedes aegypti
and Aedes albopictus
mosquitoes.
• Dengue illness is
categorized according
to level of severity as
dengue without warning
signs, dengue with
warning signs and
severe dengue.
According to the Dengue
The areas that had the
Disease Surveillance
most cases were:
Report from January 1 to
Manila – 17.92%
December 2, 2017, the
Cebu – 7.16%
Philippine regions with the
Negros Occidental –
most number of dengue
4.19%
cases last year were:
Pampanga – 4.10%
 National Capital Region Bulacan – 4.00%
(NCR) – 17.3% Cavite – 3.67%
 Region III – 15.3%
 Region IVA – 13.1%
 Region VII – 9.6%
 Region VI – 6.8%
• From January 1
to October 6,
2018, the DOH
Dengue
Surveillance
Report showed
a total of 138,444
dengue cases, up
from the 114,878
cases during the
same period in
2017.
• Death also rose from
508 in 2017 to 708 in
October of 2018.
 CLASSIFICATION
• Dengue without warning signs​​
A.1 SUSPECT DENGUE
- a previously well individual with acute febrile illness of 1-
7 days duration plus two of the following: headache, body
malaise, retro-orbital pain, myalgia, arthralgia, anorexia,
nausea, vomiting, diarrhea, flushed skin, rash (petechial,
Hermann’s sign)

A.2 PROBABLE DENGUE

-a suspect dengue case plus laboratory test: Dengue NS1
antigen test and atleast CBC (leukopenia with or without
thrombocytopenia) or dengue IgM antibody test (optional)
• A.3 CONFIRMED DENGUE
• - a suspect or probable dengue case with positive result
of viral culture and/or Polymerase Chain Reaction
(PCR) and/or Nucleic Acid Amplification Test- Loop
Mediated Amplification Assay (NAAT-LAMP) and/ or
Plaque Reduction Neutralization Test (PRNT)
B. DENGUE WITH WARNING SIGNS
- a previously well person with acute febrile illness of 1-7 days plus
any of the following: abdominal pain or tenderness, persistent
vomiting, clinical signs of fluid accumulation (ascites), mucosal
bleeding, lethargy or restlessness, liver enlargement, increase in
haematocrit and/or decreasing platelet count
C. SEVERE DENGUE
• shock (DSS)
• fluid accumulation with respiratory distress
• severe bleeding
• severe organ impairment
• Liver: AST or ALT ≥ 1000
• CNS: e.g. seizures, impaired consciousness
• Heart:and other organs (i.e. myocarditis, renal failure)
 PHASES OF DENGUE INFECTION
1. Febrile Phase
• Usually last 2-7 days
• Mild haemorrhagic manifestations like petechiae
and mucosal membrane bleeding (e.g nose and
gums) may be seen.
• Monitoring of warning signs is crucial to recognize
its progression to critical phase.
2. ​CRITICAL PHASE
• Phase when patient can either improve or deteriorate.
• Defervescence occurs between 3 to 7 days of
illness. Defervescence is known as the period in which
the body temperature (fever) drops to almost normal
(between 37.5 to 38°C).
• Those who will improve after defervescence will be
categorized as Dengue without Warning Signs, while
those who will deteriorate will manifest warning signs
and will be categorized as Dengue with Warning
Signs or some may progress to Severe Dengue.
• When warning signs occurs, severe dengue may
follow near the time of defervescence which usually
happens between 24 to 48 hours.
3. RECOVERY PHASE
• Happens in the next 48 to 72 hours in which the
body fluids go back to normal.
• Patients’ general well-being improves.
• Some patients may have classical rash of “isles of
white in the sea of red”.
• The White Blood Cell (WBC) usually starts to rise
soon after defervescence but the normalization of
platelet counts typically happens later than that of
WBC.
PATHOPHYSIOLOGY OF DENGUE FEVER
 Precipitating factors Predisposing factors
Home near a body of water Male of >15 years of age
Aedes aegypti mosquito Senior high student
Cases of dengue in their Unbalanced diet
locality

Bite of virus carrying mosquito

Mosquito transfers virus into patient

Virus penetration to the skin

Virus infects Langerhans Cell in the skin

Virus replicates inside the Langerhans Cell

Langerhans Cell release interferons

(To limit the spread of infection)

Langerhans Cells go to the lymphatics

(to lalert the immune system)

Virus infects other cells

(Macrophages and Monocytes) • Parenchymal cell death
• Cellular destruction of bone marrow
precursor cells
• Immunologic lysis of platelet cells
Virus enters the circulaton
Hepatosplenomegaly

Spread of virus results to viremia

(virus infects cells in bone marrow, spleen and liver)
Thrombocytopenia
 Infected cells produce cytokines

Activation of immune system

Increase in Lymphocytes Activation of Complement

Production of antibodies System

Antibody enhanced cytolysis Decrease in Neutriophils and Vascular endothelial activation

white blood cells

• Parenchymal cell death Release of endogenous pyrogens

• Cellular destruction of bone
marrow precursor cells
• Immunologic lysis of platelet Reset of Hypothalamus
cells
Fever

Dengue Hemorrhagic
Thrombocytopenia Fever
Thank you