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CASE CONFERENCE

CASE CONFERENCE. AMARO. AMOLENDA. ANDAL. ANG. ANG. General Data. M.C. 14, Female April 29, 1996 Filipino Roman Catholic Sampaloc , Manila Informant: Patient and Mother Reliability: Good. Chief Complaint. Fever. History of Present Illness.

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CASE CONFERENCE

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  1. CASE CONFERENCE AMARO. AMOLENDA. ANDAL. ANG. ANG

  2. General Data • M.C. • 14, Female • April 29, 1996 • Filipino • Roman Catholic • Sampaloc, Manila • Informant: Patient and Mother • Reliability: Good

  3. Chief Complaint • Fever

  4. History of Present Illness • Patient experienced fever graded > 40°C • Paracetamol 500 mg/tab Q4 • Ibuprofen 200 mg/capsule • Provided temporary relief. • Bifrontal Headache • non-radiating, graded 3/10 • (+) Non projectile vomiting of previously ingested food (1 episode) • (+) loss of appetite • (-) Epistaxis, Abdominal Pain • (-) Gum Bleeding, Dizziness • (-) Cough, Colds, Dysuria, Diarrhea 4 DAYS PTC

  5. History of Present Illness • Persistence of Fever • Ibuprofen 200 mg • It provided temporary relief of symptoms. • (+) Loss of appetite • (-) Epistaxis, Abdominal Pain, Dizziness, Vomiting, Gum Bleeding • (-) Cough, Colds, Dysuria, Diarrhea 1 DAY PTC

  6. History of Present Illness • Persistence of Fever • Ibuprofen 200mg/capsule • Provided temporary relief of symptoms • (+) Myalgia, Loss of appetite • (-) Epistaxis, Abdominal Pain • (-) Dizziness, Gum Bleeding, Vomiting • (-) Cough, Colds, Dysuria, Diarrhea 3 hours PTC

  7. Review of Systems • General:, (-) weight loss/gain • Skin: (-) rash, pigmentation • Head: (-) visual difficulties, lacrimation, aural discharge, nasal discharge • Cardiovascular: (-) cyanosis, orthopnea • Respiratory: see HPI • Gastrointestinal: see HPI

  8. Review of Systems • Genitourinary: (-) oliguria, hematuria • Endocrine: (-) heat/cold intolerance, palpitations, polyuria, polydipsia, polyphagia • Nervous: (-) convulsions, tremors, sleep problems • Hematologic: (-) easy bruisability, bleeding manifestation

  9. 24 Hour Food Recall

  10. Past Medical History • Dysentery (2005) • Confined in Hospital ngSampaloc

  11. Menstrual History • Menarche: 13 y/o • Interval: Every 28-30 days • Duration: 5-7 days • Amount: 3 fully soaked napkins • LMP: Aug 7-11, 2010 • PMP: July 5-10, 2010

  12. Immunizations • Incomplete with unrecalled dates • BCG: 1 • HepB: 3 • DPT/OPV: 3 (without booster) • Measles: 1 • MMR: (unrecalled)

  13. Family Profile

  14. Family History • (+) HPN, Paternal relatives • (+) Ovarian CA, maternal grandmother

  15. Socioeconomic and Environmental Profile • Housing Condition: • 2 storey house, made up of wood, well lit and well ventilated. Patient consumed mineral water. Garbage is collected everyday and they practice segregation. They have 2 pet dogs and no factories nearby. The family’s average monthly income amounts to >P10, 000

  16. Psychosocial History • Home: • Lives with both parents, 2 siblings and her sister’s family. Has good relationship with other family members. • Education: • Currently a 2nd year H.S. student at Ramon Magsaysay H.S. • Good school performance, and gets along with teachers and classmates. • Eating: • Eats 3x a day + snacks • Activities: • Part of Manila City Dance Scholars • Listens to acoustic music, watches TV, and surfs the net.

  17. Psychosocial History • Drugs: • Denies illicit drug use • Non smoker • Non alcoholic beverage drinker • Suicide • No suicidal ideation • Sexual • No boyfriends • Denies any sexual encounter • Safety • Follows traffic rules and regulations

  18. Physical Exam • General Survey: Conscious, coherent, ill looking, not in Cardiopulmonary distress, well nourished, and mildly dehydrated • Vital Signs- BP: 110/80, CR: 95, RR: 21, Temp: 36.5 °C • Ht: 155 cm (Z-score 0) Wt: 41.3 kg (Z-score -1)BMI: 17.2 (Z-score -1)

  19. Physical Exam • Skin: flushed skin with dry lips. Good skin turgor, no active dermatoses, and (+) Tourniquet test • Eyes/Ears/Nose/Throat: Pink palpebral conjunctivae, anictericsclerae, pupils 3-4 mm ERTL / No tragal tenderness, no ear discharge, (+) retained cerumen on both ears / non hyperemic PPA, moist buccal mucosa, no gum bleeding, no mouth sores, no palatal petechiae

  20. Physical Exam • Neck: Supple neck, no palpable cervical lymph nodes • Lungs/Chest: Symmetrical chest expansion, no retractions or alar flaring, normal AP diameter, no cyanosis, no clubbing, tactile fremiti are equal on both lung fields, resonant on all lung fields. vocal fremiti are equal on both lung fields. clear breath sounds

  21. Physical Exam • Cardiovascular:Dynamicprecordium, AB at 5th LICS MCL, no heaves, lifts, and murmurs, S1>S2 at the apex, S2>S1 at the base • Abdomen: Flabby abdomen, normoactive bowel sounds, no masses, no direct and indirect tenderness, liver and spleen not palpable • Musculoskeletal: No inflammation and pain on both knees, no limitation of motion

  22. Physical Exam • Spine: Midline, No deformities along the vertebra • Pulse: full and equal on all extremities • External genitalia: no clitoromegaly • Tanner stage: Breast bud:2 Pubic Hair: 2

  23. Physical Examination • Neurologic Examination • Conscious, coherent, oriented to three spheres • Opens eye spontaneously, Oriented, Obeys command • No anosmia • 20/40 on L and R eyes, (+) confrontation, midline gaze, (+) direct and consensual light reflex, intact pupillary light reflex, (+) ROR • EOMs full and equal • Can feel light touch equally on the forehead, cheeks, mandibular area

  24. Physical Examination • Neurologic Examination • Can raise both eyebrows, can frown, smile, and can puff out both cheeks • No hearing deficits, no lateralization • Uvula midline, rises on phonation • Can raise shoulder against resistance on the left • Tongue midline on protrusion

  25. Physical Examination • Neurologic Examination • MMT 5/5 on all extremities • Can perform FTNT and APST • Sensitive to pain, temperature, light touch, and vibration • DTRs ++ on all extremities, (-) Babinski

  26. Salient Features • 14 y/o, Female • Sampaloc, Manila • 4 day Fever • Bifrontal Headache • Vomiting (1 episode) • (-) Epistaxis, Abdominal Pain, Dizziness, Gum Bleeding • (+) Loss of appetite, Myalgia • (-) Cough, Colds, Dysuria, Diarrhea • Flushed skin with dry lips • Good skin turgor • (+) Tourniquet test • No palatal petechiae

  27. APPROACH TO DIAGNOSIS • A presenting manifestation pointing to the least number of diseases Dengue Hemorrhagic Fever Influenza Typhoid Fever Leptospirosis Fever with Constitutional Symptoms

  28. WORKING DIAGNOSIS • Acute Viral Infection to r/o Dengue Fever with probable signs

  29. Diagnostic Plans • Complete blood cell count with Platelet

  30. Complete Blood Count • Hemoconcentration (hematocrit increased 20%) – precedes shock • Thrombocytopenia (platelet count <100 x 109/L) are seen in dengue hemorrhagic fever or dengue shock syndrome and occur before defervescence and the onset of shock. • Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness • Lymphocytosis, with atypical lymphocytes, commonly develops before defervescence or shock. • Monitor CBC at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever

  31. Treatment Plans Supportive • Paracetamol 500mg/tab, 1 tablet PO every 4 hours for temperature >38.5 • Oral rehydration solution 75 replace losses volume per volume • Increase oral fluid intake (water, soups, juice, milk) • Bed rest

  32. Treatment Plans Supportive: • Avoid dark colored foods • Watch out for warning signs (severe abdominal pain, passage of black stools, bleeding into the skin or from the nose or gums, sweating, and cold skin ) • Observe carefully for complications for at least 2 days after recovery from fever.

  33. Treatment Plans Preventive 1.) Prevent mosquito bites: • Wear full-sleeve clothes and long dresses to cover the limbs. • Use of mosquito repellents • Use of mosquito nets to protect babies, old people and others who may rest during the day. • Permethrin (pyrethroid insecticide) treatment on mosquito nets, curtains to repel or kill mosquitoes.

  34. Treatment Plans Preventive 2.) Prevent the multiplication of mosquitoes: • Mosquitoes which spread dengue live and breed in stagnant water in and around houses. Drain out the water from bottles, tanks, barrels, drums, buckets, etc. • All stored water containers should be kept covered at all times.

  35. BRIEF DISCUSSION

  36. Dengue Viral Replication Cycle • Family Flaviviridae • Genus Flavivirus • Small, enveloped viruses containing a single-stranded RNA genome of positive polarity • Vector: Aedesaegypti

  37. Dengue Viral Replication Cycle • Attachment to the cell surface • Entry into the cytoplasm • Translation of viral proteins • Replication of the viral RNA genome • Formation of virions (encapsidation) • Release from the cell

  38. Incubation Period • Symptoms typically develop between 4 and 7 days (3-14 days)

  39. DENGUE FEVER • Acute febrile illness accompanied by: • Headache • Retroorbital pain • Marked muscle and joint pains - "break-bone fever“ • Fever typically lasts for 5-7 days • Some patients display a biphasic ("saddleback") fever curve, with the second febrile phase lasting 1-2 days • The febrile period may also be followed by a period of marked fatigue that can last for days to weeks

  40. DENGUE FEVER • Constitutional symptoms • Fever and headache • Eye pain • Body pain • Joint pain • Rash • Gastrointestinal symptoms • Nausea or vomiting • Diarrhea • Respiratory tract symptoms • Cough • Sore throat • Nasal congestion

  41. DENGUE FEVER • Physical examination • Non-specific • Fever • Rash – macular or maculopapular • Conjunctival injection, pharyngeal erythema, lymphadenopathy, and hepatomegaly

  42. DENGUE FEVER • Laboratory findings • Leukopenia • Thrombocytopenia • Serum aspartatetransaminase (AST) levels are frequently elevated

  43. COMPARISON OF CLINICAL FEATURES AND HEMATOLOGIC ABNORMALITIES BETWEEN DENGUE FEVER AND DENGUE HEMORRHAGIC FEVER AMONG CHILDREN IN THE PHILIPPINES CELIA C. CARLOS, KAZUNORI OISHI*, MARIA T. D. D. CINCO, CYNTHIA A. MAPUA, SHINGO INOUE, DEU JOHN M. CRUZ, MARY ANN M. PANCHO, CAROL Z. TANIG, RONALD R. MATIAS, KOUICHI MORITA, FILIPINAS F. NATIVIDAD, AKIRA IGARASHI, AND TSUYOSHI NAGATAKE

  44. Objective: To demonstrate the differences of clinical features and hematologicabnormalities between dengue fever (DF) and dengue hemorrhagicfever (DHF). • Methods: • 359 pediatric patients admitted St. Luke’sMedical Center in Quezon City, between 1999 and 2001 in MetroManila, and adjoining provinces the Philippines, with a laboratory-confirmeddengue virus infection were evaluated. • Results: • One third of the patientshad DHF, and most of these patients were without shock.

  45. Restlessness,epistaxis, and abdominal pain were more associated with DHF. • The platelet count was significantly lower in the DHF groupthan in the DF group before and after defervescence. • In theDHF patients, the hematocrit was significantly increased beforedefervescence, and decreased the day after due to administrationof intravenous fluid. • Coagulation abnormalities associated withmost DHF patients were thrombocytopenia and an increased fibrinolysis,but not disseminated intravascular coagulation.

  46. Thank You.

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