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<3 CRISTAL

GRANDROUNDS
Case Protocol
July 2, 2015

Presentor: LEC 11
Leandro Victor Arcena Jerrhel Kathleen Dahino
Maria Cristina Garbo Alfonso Victor Luna
Micaela Kristina Paz Karen Sarmiento
Louise Gabrielle Valdez

Identifying Data:
MPV, 11 year old female, catholic, a resident of Pasig City, admitted for the second time at The
Medical City.

Chief Complaint: Fever with throat pain

History of Present Illness:

Three days prior to admission, the patient complained of fever with highest temperature of 39C,
associated with generalized headache of 7/10, non-positional dizziness, and throat pain, itching quality of
6/10. There was no vomiting, diarrhea, or abdominal pain. The patients mother gave her Paracetamol
500mg (10mg/kg/dose), which afforded temporarily relief of fever and headache. The patients fever and
headache recurred the following day. When asked, the patient had no symptoms of myalgia, and no
previous episodes of spontaneous epistaxis or mucosal bleeding. No consult was done.
Twelve hours prior to admission, due to the persistence of symptoms, the patient sought consult at
another institution where a Rapid NS1 Dengue Antigen test was done, which showed positive results. She
was then advised admission at that institution, but opted for transfer to our institution.
Eight hours prior to admission, the patient was then seen at the ER, complaining of weakness,
poor appetite, and itching throat pain of 6/10. Patient was still febrile and was then advised for admission
to the pediatric ward.

Review of systems:
General: No weight loss, no easy fatigability
Head: No blurring of vision, no tinnitus, no ear discharge, no dizziness
Respiratory: No cough, no colds, no dyspnea
Cardiovascular: No chest pain, no palpitation
Gastrointestinal: No bleeding, no abdominal pain
Genitourinary: No dysuria, no nocturia, no hematuria
Psychiatry: No disorientation, no mood changes
Neurology: No seizures, no weakness

Past Medical History:

 The patient is a known asthmatic, with last asthmatic attack when she was 6 years old (2010). She
is taking no maintenance medication.
She was previously hospitalized for Dengue fever without warning signs for 5 days at our
institution in 2008, in the pediatrics ward.
No previous surgeries, no allergies to food or medication.

Family History:
The patient has no family history of asthma, hypertension, diabetes, cancer, or bleeding disorders.
Her two elder siblings were also previously hospitalized for Dengue fever.

Maternal and Birth History:

The patient was born pre-term at 30 weeks via normal spontaneous delivery to a 29 y/o G4P3
(3013) of unrecalled birthweight at a private hospital. Aside from prematurity, no fetomaternal
complications noted. No work-up or admission was done.

Immunization History:
The patient was immunized with the following vaccines with her regular pediatrician.
BCG: 1 dose
DPT: 3 doses
OPV: 3 doses
Hepa B: 3 doses
Measles: 1 dose
MMR: 1 dose
Varicella: 1 dose
Hepatitis A 2 doses
HiB: 1 dose
PCV: 1 dose

Gynecologic History
The patient had her menarche at 9 years old. Her last menstrual period was on June 22. She has a
regular menstrual period with interval of 1 month, using around 3 pads per day.

Personal and Social History:

Home The patient lives with her parents and 2 siblings. She has good interpersonal
relationship with her parents, and oldest sibling. She occasionally argues with her
elder sister.
Education The patient is an incoming grade 8 student with good grades.
Eating Habits The patient has a regular diet, with occasional sweets and candies.
Activities She is a student athlete and plays for the volleyball team.
Drugs No illicit drug use
Sexual Activity The patient has no boyfriend, and denies any sexual activity
Suicidal Ideation None

Physical Examination:
General Survey: The patient was awake, alert, and cooperative. She did not seem to be in pain, and was
not in cardiorespiratory distress.

Vital Signs: BP 100/70 mmhg CR 96 bpm RR 20 cpm T 39.9C

Anthropometrics: Wt 63 kg Ht 160cm BMI 24.6 kg/m2

Fundoscopy: Not assessed.

HEENT: Eyes
Eyes are aligned, non-sunken, with pale conjunctivae, anicteric sclera, no lid lag; pupils
equally round and responsive to light, equal accommodation, extraocular movements are
intact.

Ears
No visible scars or lesions, no discharge. No deformity. Weber and Rinne test not done.

Nose
Midline, no deformities. No discharge.

Mouth
No oral lesions. No oral mucosal bleeding. No carries.

Neck
Slightly hyperemic pharyngeal wall, slight tonsillopharyngeal congestion. No palpable
masses, no palpable lymph nodes, no tenderness; trachea in the midline; no palpable
thyroid enlargement.

Chest: No retractions. No use of accessory muscles. No areas of tenderness. Clear

bronchovesicular, with no adventitious breath sounds auscultated anteriorly.

Heart: Adynamic precordium. Regular chest shape. Apex beat felt at the 5th ICS-MCL. No
visible scars, lesions, masses on anterior chest wall. No palpable masses. No heaves, lifts
or thrills felt. Regular heart rhythm. S1 louder than S2 at the apex, S2 louder than S1 at
the base. Physiologic splitting of S2 was heard. No murmurs, no gallops.

Abdomen: Flat abdomen, no visible scars, and masses. 18 Bowel sounds heard in one minute. No
bruits heard over the abdominal aorta. Tympanitic upon percussion in all quadrants. No
palpable masses. No areas of tenderness. Skin turgor less than 2 seconds.

Extremities: Nails
With pallor of nail beds of fingers, no clubbing, no gross deformities, no inflammation

Upper extremities
Full and equal radial pulses. Warm, no edema.

Lower extremities
Full and equal dorsalis pedis pulses. Warm, no edema. Capillary refill time less than 2
seconds.

Pelvic: Grossly female. Genital exam not done.

Neurologic examination:
Conscious, coherent, GCS 15
Cranial Nerve I: No anosmia
II: Pupils 2-3 mm bilaterally reactive to light
III, IV, and VI: Full range of motion of Extraocular muscles
VI: (+) Corneal reflex
VII: No facial asymmetry
VIII: Intact gross hearing
IX and X: (+) gag reflex
XI: Can shrug shoulders
 XII: Tongue midline
Motor: 5/5 on all extremities
Cerebellar: Can do alternating hand movements
Reflexes: 2++ on all extremities
Sensory: No sensory deficit

Initial Impression:
Dengue Fever without warning signs
Acute Tonsillopharyngitis

Course in the Ward:

Upon examination at the ER, the patient was hooked to D5LR 1L at 75mL/hr (2cc/kg based on
IBW) for hydration, owing to her febrile state. She was also given Paracetamol 500mg tablet
(10mg/kg/dose) to be taken once every 6 hours for her fever, as well as oral rehydration salts (Hydrite)
one sachet in 200mL water to be given every 6 hours for supplementary hydration. Laboratory work-up
was requested with a complete blood cell count with platelet count in order to check for infection, as well
as to monitor her hematologic profile. Upon admission, her IV fluid was shifted to 3cc/kg, now at
108mL/hr for increased hydration, since she still had signs of dehydration (dry lips). Repeat CBC was
also requested at every 6 hours for serial monitoring of hematologic profile. Input and output monitoring
was also instituted to monitor her fluid intake.

On the first hospital day (fourth day of illness), the patient was diagnosed with Dengue fever with
no warning signs, due to her presentation of poor appetite, body malaise, and positive NS1 result. She was
still febrile (highest temperature of 39.5C), but with no current headache, no abdominal pain, no
vomiting, or loose stools. She also did not show signs of dehydration, hence current IV fluid was
maintained. Current diagnostic and supportive management was then maintained.

On the second hospital day (fifth day of illness), the patient was still febrile (highest temperature
of 40.3C), but with no headache, abdominal pain, vomiting, loose stools, or signs of dehydration. Aside
from her serial CBC-PC, serum electrolytes were also assessed, which showed low potassium
(3.30mmol/L) and calcium (2.00mmol/L). To replenish these, the IV fluid was shifted to 126mL/hr
(3.5cc/kg). Banana was also added to her diet for greater potassium intake.

On the third hospital day (sixth day of illness), the patient was now afebrile (highest temperature
of 36.7C), and complained of slight tenderness on the epigastric area. Otherwise, physical examination
results were unchanged. She was maintained on her current IV fluid. She was then started with
omeprazole 20mg IV once daily, with a warm compress on her abdominal area for her pain.

Later that day, CBC test results show a Hematocrit of 0.50, as well as a platelet count of 92. Her
vital signs monitoring was then stepped up to every 2 hours, with another CBC-PC to check for possible
hemoconcentration. For fluid management in case of hemoconcentration, her IV fluid was increased to
144mL/hr (4cc/kg of IBW). Oral rehydration salt therapy was also increased to every 4 hours. The patient
was examined, which showed that the patient had no vomiting, good appetite, and a good urine output
(1.3cc/kg/hour). However, physical exam showed again dry lips, slightly cold extremities, and a now
palpable liver edge of 1-2cm. For increased hydration, her IV fluid was shifted from D5LR to plan LR.
She was also scheduled for another test of CBC-PC, and serum electrolytes. She was also requested to
have creatinine kinase test to check for possible muscle inflammation (which showed an elevated CK-MB
of 27.00 U/L). Otherwise, other supportive management was unchanged.
 On the fourth hospital day (seventh day of illness), the patient was still afebrile (temperature of
36.1C), with stable vital signs (HR: 64bpm, RR: 22 cpm, BP 90/60), good urine output (1.5cc/kg/hr).
Patient had no noted bleeding episodes, no difficulty in breathing, and no chest pain. She also had no
more complaints of abdominal pain. Her appetite was fair. Physical exam results showed moist lips, clear
breath sounds, soft and non-tender abdomen, full and equal pulses, with warm extremities. Liver edge
was still palpable at 1-2cm. Her CBC results showed decreased hematocrit to 0.48, as well as platelet to
108. Current supportive and therapeutic management was maintained, with close monitoring via CBC-PC
still in effect. A few hours later, upon reassessment, her IV fluid was then readjusted to 108ml/hr (3cc/kg
of IBW) to compensate for her improved hydration status.

On the fifth hospital day (eighth day of illness, third day afebrile) the patient had a stable
condition, with still stable vital signs, good urine output, good appetite, and no complaints of pain. Her
physical exam results were unchanged, with still clear breath sounds, good hydration status, and warm
extremities. Liver was still slightly palpable at 1cm. Current diagnostic and therapeutic management was
maintained. Her hematologic profile was now in better condition, with slowly decreasing hematocrit
(0.47), increasing platelet (120), and decreasing lymphocytes (now 0.61, from 0.72 at the second hospital
day)

The following day, owing to improved condition, as well as stable hematologic profile, the patient
was scheduled for discharge from the pediatric ward.

Final Diagnosis:
Dengue Fever, with warning signs

Laboratory/Diagnostics

Complete Blood Count with Platelet Count

Day of Febrile Date Test Hg Hct Platelet RBC WB Neutrophi Lymphocyte

Illness ? number C l
4th day Yes 24-Jun 1 150 0.45 150 5.25 2.2 0.56 0.36
5th day Yes 25-Jun 1 154 0.46 100 5.59 4.3 0.62 0.3
2 153 0.47 98 5.59 2.5 0.34 0.59
6th day No 26-Jun 1 168 0.5 108 6.01 5.2 0.2 0.69
2 168 0.5 92 6.05 6.6 0.2 0.72
3 168 0.5 108 6.01 5.2 0.2 0.69
4 163 0.49 108 5.88 9.2 0.23 0.71
7th day No 27-Jun 1 159 0.47 115 5.54 9.3 0.22 0.69
2 160 0.47 120 5.76 8.5 0.3 0.61
8th day No 28-Jun 1 150 0.45 100 5.35 6.4 0.26 0.68
2 161 0.48 112 5.82 7.3 0.36 0.6

Serum Electrolytes (June 25, 2015)

Total Calcium Sodium Potassium

(reference: 2.23-2.50 mmol/) (reference: 136.00-145.00 mmol/L) (reference: 3.50-5.10 mmol/L)
2.00 mmol/L 139 mmol/L 3.3 mmol/L
Creatinine Kinase (June 26, 2015)
Total CK CK-MB CK -MM
(reference: 29.0-168.0 U/L) (reference: 0.0-24.0 U/L) (reference: 29.0-144.0 U/L)
46.00 U/L 27.00 U/L 19.00 U/L

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