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G P O N D U T Y : D R . T I K AR E S I D E N T O N D U T Y : D R . E V I R O S S A
C O - A S S O N D U T Y :
L E O N Y N E R R Y S . T A M B U N A N
R A D E N A N N I S A C I T R A P E R M A D I
DUTY REPORT WARD UNIT
22NDOCTOBER , 2014
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PATIENTSRECAP
3rdfloor
Nasopharingeal Carcinoma
4thfloor POST SYNCOPE
IBD
Anemia, with susp. Pneumonia
SIDA
6thfloor
DHF
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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 : 22nd October , 2014 at 01.00WIB
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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 baselinetemperature
No fever prior to admission (day 4)
Associated with diarrhea, 7 times a day on the 4thday > thestool is watery, no blood, no mucus, no pus, no waste, not oilynor smelly with yellow brownish color.
Nausea and Vomiting (+), 3 times a day, food containing vomit
Autoanamnesa at 01.00 WIB on 22ndOctober 2014
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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 thesecomplaints.
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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
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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)
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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 (-)
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PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION
Thorax
Pulmonary Examination
Inspection : normochest, symmetrical chest movement on staticand dynamic. ICS retraction (-), no rash
Palpation : symmetrical chest expansion and tactile fremitus, (-)mass, (-) tenderness
Percussion : sonor at both lung field
Auscultation : bronchovesicular +/+, rhonchi -/-, wheezing -/-
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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 (-)
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PHYSICIAL EXAMINATION
PHYSICAL EXAMINATION
Abdominal examination
Inspection : not distended, mass(-)
Auscultation : normal bowel sound ; 8x/min
Palpation : tenderness and rebound tenderness alll overregio (-),hepatomegaly and splenomegaly (-)
Percussion : timpani
Special examination : shifting dullness (-), fluid wave (-)
Rumple Leed : +
Extremities: warm skin, pale (-) CRT
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RUMPLE LEED
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RUMPLE LEED
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RESUME
Male, 25 y.o, came with fever since 4 daysbefore admission, with no rash, anybleeding from gum, nose, bloody stool or
urine, headache , retroorbital pain, rash,abdominal pain, myalgia, shortness ofbreath. On physical examination, vital signsare normal, percussion on both lung fields
are sonor, there is no sign of peuralefussioin nor asictes and the positiverumple leed test. On the work up lab,patient has hemoconcentration andtrombocytopenia.
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LIST OF PROBLEMS
1. Acute Fever
2. Nausea and vomiting
3. Diarrhea
4. Obese
5. Hemoconcentration
6. Thrombocytopenia
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DIAGNOSIS
Working diagnosis
Dengue Hemorrhagic Fever gr I
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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 thefollowing: 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 vascularpermeability 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 ofplasma leakage such as pleural effusion, ascites orhypoproteinaemia
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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
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FLUID REPLACEMENT
LOADING DOSE
5-7 ml/kg/hr 1-2 hr500 cc in 1-2hr
3-5 ml/kg/hr in 2-4 hr300 cc in 2-4hr
2-3 ml/kg/hr or less according toclinical response
200 cc/hr
Monitor VS (4 hourlyurine output(4-6hrly)Hct(before & after fluidreplacement then 6-12hrly)
BG
MAINTANANCE
1500 + 20 (BB-20)
1500 + 20 (96-20)3020 ml/24 hr
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PROGNOSIS
Quo ad Vitam: bonam
Quo ad functionam: bonam
Quo ad sanactionam: bonam
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REFERENCES
DENGUE
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EPIDEMIOLOGY
Most important arthropod-borne viral diseases interms of human morbidity and mortality.
Important public health problem.
Tropical & subtropical regions around the worldurban and semi urban areas
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VIROLOGY
Dengue virus
mosquito-borne flavivirus.
Transmitted by
Aedes aegypti Aedes albopictus.
DEN-1, 2, 3 and 4.
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VIROLOGY
Each episode of infection
a life-long protective immunity to the homologous serotype
partial & transient protection against subsequent infectionby the other three serotypes.
Secondary infection is a DHF major risk factor
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VIROLOGY
Other important contributing factors for DHF are
viral virulence
host genetic background
T-cell activation
viral load
auto-antibodies
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SPECTRUM OF INFECTION
The incubation period is 4-7 days (range 3-14)
Asymptomatica spectrum of illness
Undifferentiated mild febrile illnesssevere disease
(plasma leakage (-/+_) & organ impairment Systemic & dynamic disease with
Clinical
Haematological
Serological profiles changing from day to day.
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PATHOPHYSIOLOGY
Increased vascular permeability is the primarypathophysiological abnormality in DHF/ DSS.
Increased vascular permeability leads to plasma
leakage and results in hypovolaemia/ shock.
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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
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TOURNIQUET TEST
In DHF grade 1(+) tourniquet test serves as theonly indicator of haemorrhagic tendency.
Sensitivity0% to 57% (phase of illness)
5-21%false positive
How to perform tourniquet test
Inflate the blood pressure cuff on the upper arm toa point midway between the systolic and diastolic
pressures for 5 minutes.
A positive test is when 20 or more petechiae per2.5 cm (1 inch) square are observed.
The 1997 WHO classification of dengue virus infection
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The 1997 WHO classification of dengue virus infection.
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DFProbable
An acute febrile illness with two or more of thefollowing manifestations: headache, retro-orbitalpain, myalgia, arthralgia, rash, haemorrhagicmanifestations and leucopenia
And
Supportive serology (a reciprocalhaemagglutination-inhibition antibody titre >1280, acomparable IgG enzyme-linked immunosorbentassay (ELISA, see chapter 455) titre or a positive IgM
antibody test on a late acute or convalescent-phaseserum specimen)
Or
Occurrence at the same location and time as otherDF cases
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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 autopsytissue serum or cerebrospinal fluid samples by polymerase
chain reaction (PCR)Reportable Any probable or confirmed case should be reported
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DHFFor 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; adecrease in the haematocrit after intervention >20% ofbaseline; signs of plasma leakage such as pleuraleffusion, ascites or hypoproteinaemia
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DSS
For a case of DSS, all four criteria for DHF must bemet, in addition to evidence of circulatory failuremanifested 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
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World Health Organization. DengueGuidelines for Diagnosis, Treatment,Prevention and ControlNew Edition 2009. WHO: Geneva; 2009
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The following manifestations are important indengue infection but are often under- recognisedor misdiagnosed
Acute abdomen :
Hepatitis and liver failure :
Neurological manifestation :
Haemophagocytic syndrome
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DISEASE MONITORING LABORATORY
TESTS
Full Blood Count (FBC)
1. White cell count (WCC) :
2. Haematocrit (HCT) :
3. Thrombocytopaenia :
Liver Function Test
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DIAGNOSTIC TESTS
DENGUE SEROLOGY TESTS
Haemagglutination Inhibition Test
Dengue IgM test
Indirect IgG ELISA test Cross-react with:
other flavivirusJapanese Encephalitis
non-flavivirusmalaria, leptospirosis, toxoplasmosis, syphilis
connective tissue diseasesrheumatoid arthritis
VIRUS ISOLATION POLYMERASE CHAIN REACTION (PCR)
NON-STRUCTURAL PROTEIN-1 (NS1 Antigen)
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Clinical and Laboratory Criteria for Patients Who Can be Treated atHome
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The following should be taken into considerationbefore discharging a patient.
Afebrile for 48 hours
Improved general condition
Improved appetite
Stable haematocrit
Rising platelet count
No dyspnoea or respiratory distress from pleural effusionor ascites
Resolved bleeding episodes
Resolution/recovery of organ dysfunction
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THANK YOU
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