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SY 2010-2011
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SUBMITTED TO:
KHRISTEL ANNE G. BUTAC
CLINICAL INSTRUCTOR
PERSONAL PROFILE
Case No.: 8126
Address: Nayon,Lamut,Ifugao
Sex: Female
Age: 2 7/12
Nationality: Filipino
Time of Admission: 2 PM
ADMISSION HISTORY
The patient usually suffers from illnesses such as diarrhea, cough and colds. The patient has no food, drug and environmental
allergies. The child had not acquired other disease than cough and colds. The child had a complete immunization. The mother and
father does not have a history of disesaes of familial tendency.
Dengue [DEN-ghee] is a flu-like viral disease spread by the bite of infected mosquitoes. Dengue hemorrhagic fever is a severe,
often fatal, complication of dengue.
Dengue Hemorrhagic Fever – those cases with gross hemorrhages and with etiologic agent identified; a severe illness endemic in most
of tropical Asia, characterized by abnormal vascular permeability, hypovolemia and abnormal blood clotting mechanism.
There are four serotypes of Dengue Virus (1,2,3 and 4 Group B Arbovirus). It has been reported that although antigenetically close to
each other, they may give only partial cross-protection, after being infected by any of them.
Three other Arbovirus: Chikungunya, O’nyong-nyong and West Nile Fever, have been identified with dengue-like diseases.
Dengue Fever is transmitted by the bite of an infected mosquito. The viruses that cause it are maintained in a cycle that involves
humans and a domestic, day-biting mosquito that prefers to feed on humans. Once infected, a mosquito remains infective for life.
The dengue fever mosquito (Aedes aegypti) is dependent on humans and never lives more than 90 meters from dwellings, thus
guaranteeing her meals. The sound of her wings cannot be heard and she attacks from below or behind, e.g. underneath chairs and
mainly at the feet and ankles. This mosquito is domestic, day-biting with low and limited flying movements.
Transmission occurs by bite of Aedes aegypti female mosquitoes – the same vector of urban yellow fever – a day-active species with
low fly-autonomy that is abundant in and around human habitations. The females are very nervous feeders, disrupting the feeding
process at the slightest movement, only to return to the same or a different person to continue feeding moments later. Because of this
behavior the mosquito will often feed on several persons during a single blood meal and, if infective, may transmit the dengue virus to
many people in a short time. It is not uncommon to see several members of the same household become ill with dengue fever within a
24-36 hour frame, suggesting that a single infective mosquito infected all of them.
Sources:
1. Infected Persons- the virus is present in the blood of patients during the acute phase of the disease and will become a reservoir
of virus, accessible to mosquitoes which may then transmit the disease.
2. Stagnant water within the household and premises are the usual breeding places
Mode of transmission
By the bite of an infective Aedes Aegypti mosquito, viruses have been isolated from this mosquito during epidemic.
Incidence
1. Age: the infection may occur at any age but it is common among school children with the peak between 4 and 6 years old.
2. Sex: both sexes equally affected.
3. Season: more frequent during rainy season or months.
4. Geographical: more prevalent in urban communities or localities.
CLINICAL MANIFESTATIONS
First 4 Days
4th-7th Days:
7th-10th Days:
Severe Manifestations:
Usually, the result of a second dengue viral infection.
CLASSIFICATION:
Severe, Frank type- with flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in
recovery or death.
Mild- with slight fever, with or without petechial hemorrhage but epidemiologically related to typical cases usually discovered in the course of
investigation of typical cases.
INCUBATION PERIOD
Uncertain. Probably 6 days to one week.
PERIOD OF COMMUNICABILITY
Man: 1 day before febrile period until the end of it
Mosquito: 8-12 days after blood meal
RISK FACTOR
AGE
IMMUNOSUPPRESSED PATIENTS
DIAGNOSTIC TEST
Blood test
Tourniquet test
Tourniquet test (Rumpel Leads Test)
Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes.
Release cff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa.
Count the number of petechiae inside the box.
*A test is positive when 20 or more petechiae per 2.5 cm square or 1 inch square are observed.
TREATMENT
There is no specific treatment for dengue. Persons with dengue fever should rest and drink plenty of fluids. They should be
kept away from mosquitoes for the protection of others. Dengue hemorrhagic fever is treated by replacing lost fluids. Some patients
need transfusions to control bleeding.
PREVENTION
1. MINIMIZE MOSQUITOES:
To minimize mosquito bites it is obvious that mosquito-prone areas (such as vessels holding water, discarded cans and
bottles, and old tire half submerged in swampy water) should be avoided.
2. UNDERSTAND THE BASIC BEHAVIOUR AND FEEDING HABITS OF THE MOSQUITO CARRIER. The adult
mosquito prefers to live indoors and feed on humans during 2 peaks of biting activity: early morning for 2-3 hours after
daybreak and in the afternoon several hours before dusk.
3. SCREEN OR AIR-CONDITION ROOMS
4. BURN MOSQUITO COILS in the immediate area. CARE is suggested here because breathing problems, or even asthma,
may rarely develop. Electric plug chemicals will also help to repel mosquitoes from a room.
5. AVOID PERFUMES : mosquitoes are attracted to scents.
6. WEAR LONG SLEEVES AND PANTS, AND AVOID DARK CLOTHES. Light colored clothing should cover the arms and
legs.
7. SPRAY A " KNOCK DOWN" INSECTICIDE in sleeping and living areas at dusk.
8. USE A SKIN-SPRAY INSECT REPELLENT. 80% DEET (N.N-diethyl-m- toluamide) may be used by adults, but should not
be applied to babies, and only sparingly (quick sprays, 2-3 in 24 hours) to children 6-24 months, because of the potential of
toxic effects. Children and pregnant women are recommended to use a natural insect repellent with citronella or eucalyptus
(available from WORLDWISE OnLINE).
9. PERMETHRIN is an insecticide that can be used to soak mosquito nets and protective clothing
ANATOMY AND PHYSIOLOGY
.BLOOD
-Is a specialized bodily fluid that is composed of a liquid called blood plasma and blood cells suspended within the plasma.
Plasma
-is the liquid component of blood, in which the blood cells are suspended.
Blood Cells
-is any cell of any type normally found in blood. These fall into three general categories:
Red blood cells
White blood cells
Platelets
is circulated around the body through blood vessels by the pumping action of the heart.
hematopoiesis is the process of blood formation, which primarily occurs in the red bone marrow (skull, pelvis, ribs, sternum &
proximal epiphyses of the humerus & femur.
BONE MARROW
-is the site of hematopoeisis,or blood cell formation. All skeletal bones are involved in children, but as children age, marrow
activity is usually limited to the pelvis,ribs,vertebrae, and sternum in adults. Marrow is one of the largest organs of the body, making
up to 4% to 5% total body weight. The marrow is highly vascular. Within it are primitive cells called stem cells. The stem cells have
the ability to self replicate, thereby ensuring a contnuous supply throughout the life cycle. When stimulated to do so, stem cells can
begin a process of differentiation into either myeloid or lymphoid stem cells. These stem cells are committed to produce specific types
of blood cells. Lymphoid stem cells produce either T or B lymphocytes. Myeloid stem cells differentiate into three broad cell types:
erythrocytes, luekocytes, and platelets.
PLASMA 55%
CONSTITUENT MAJOR FUNCTIONS
Granulocytes:
Lymphocytes
1500-3000(20-45% of
WBC”s)
Monocytes
100-700(4-8% of WBC”s)
PLATELETS 250,000-500,000 > needed for normal blood clotting; initiate clotting cascade by
clinging to broken area; help to control blood loss from broken
blood vessel
Erythropoietin stimulates
red bone marrow to
enhance erythropoiesis
Erythrocytes develop from committed stem cells through reticulocytes to mature erythrocytes
in about 7 days and live a total of about 120 days.
aging erythrocyte undergoes changes in its plasma membrane, making it susceptible to
recognition by phagocytes and subsequent phagocytosis in the spleen & liver.
B. LEUKOCYTES
LEUKOCYTES or white blood cells are far less numerous than red blood cells they are
crucial to body defense against disease. White blood cells are the only complete in the blood that is
they contain nuclei and the usual organelles. Leukocytes form a protective movable army that helps
defend the body against damage the bacteria, virus’s parasites and tumors cells. The circulatory system are simply their means of
transportation to areas of he body where their services are needed in the inflammatory and immune response.
GRANULOCYTES are granule containing WBCs. They have lobed nuclei w/ typically consist of several rounded nuclear areas
connected by thin strands of nuclear material. The granules in their cytoplasm stain specifically w/ Wright stain. The granulocytes
include the nuetroplis, eosinophils, and basophils.
Fig. 1.3-
a. Viscosity - blood is more viscous than water. Changing the % of cells, cellular fragments, plasma proteins orLeukocytes
other dissolved
substances changes the viscosity. Viscosity is increased if either the plasma (fluid) is decreased (ex. during dehydration) or if
the substances within the blood are increased (ex. polycythemia)
b. Concentration the cells (red blood cells and white blood cells) that are dissolved within the plasma are dependent on the
concentration of the plasma because water is free to move into or out of the cell by osmosis. Normally, the plasma is isotonic
to the cells. If however, the plasma becomes hypertonic, the cells will lose water and shrink. A process called crenation. If
the plasma becomes hypotonic, the cells will take on water and swell. If they take on too much water, they could burst. A
process called hemolysis. Maintaining plasma concentration is essential for the integrity of these cells.
c. Volume - A typical female has 4-5 liters of blood and a typical male has 5-6 liters of blood. Maintaining blood volume is
essential in maintaining blood pressure. If blood pressure drops below a critical level, blood delivery throughout the body is
impaired and death is probable.
d. pH - plasma proteins, like all proteins of the body, have a 3-dimensional shape that is dependent on the correct amount of
hydrogen (and hydroxyl) ions being present. If the pH is altered from the normal value of 7.35-7.45, the plasma proteins lose
their 3-D shape and are denatured and unable to carry out their functions.
e. Temperature - the enzymes of the body are responsible for all of the chemical changes that occur. The function of enzymes to
work properly is dependent on temperature. Enzymes work efficiently at body temperature. Below body temperature, the
enzymes work more slowly. They can slow down enough to not be able to meet the needs of the body. If the temperature
rises, the enzymes will work more efficiently but, if the temperature is raised too high (106 or so) they are denatured, resulting
in brain damage and perhaps death. The function of the blood is to pass through the hypothalamus of the brain to be monitored
for temperature. If blood temperature is too high or too low, homeostatic mechanisms are initiated to reestablish normal body
temperature
C. PLATELETS
a. Platelets are not cells, they are fragments of bizarre multinucleated cells called megakaryocytes, which rupture,
releasing thousands of anucleated “pieces” that quickly seal themselves off from surrounding fluids.
b. Appear as dark staining irregulary shape body scattered among the other blood cells.
A. Systemic circulation
Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to
the body, and returns deoxygenated blood back to the heart.
B. Pulmonary circulation
Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the
heart, to the lungs, and returns oxygenated blood back to the heart.
C. Coronary circulation
LIVER
is the largest internal organ in the human body
normally weighs between 1.4 - 1.6 kilograms
it is a soft, pinkish-brown organ.
It is located on the right side of the upper abdomen below the diaphragm.
The liver lies to the right of the stomach and overlies the gallbladder
PATHOPHYSIOLOGY
LABORATORY RESULTS
HEMATOLOGY
-is a series of tests used to evaluate the composition and concentration of the cellular component of blood
- this Lab. Study is also indicated to know any suspected anemia and the response to the treatment, blood loss and the response
to blood replacement.
Elevated RBC’s suggest inadequate tissue oxygenation. Hypoxia stimulates renal secretion of erythropoetin. This stimulates
the bone marrow to increase the RBC production.
Elevated WBC’s may indicate infectious heart diseases and myocardial infarction.
Hematocrit is the ratio between the RBC and the Plasma.
-Decreased in severe anemias, anemia of pregnancy, acute massive blood loss.
-Increased in erythrocytosis of any cause, and in dehydration or hematoconcentration associated with shock.
Hemoglobin
-Decreased in various anemias, pregnancy, severe or prolonged hemorrhage, and with excessive fluid intake.
-Increased in polycythemia, COPD, failure of oxygeb because of heart failure, and normally in people living in high altitudes.
Hemoglobin F
-Increased in infants and children, and in thalassemia and many anemias
Neutrophils
-Increased with acute infections, trauma or surgery, leukemia, malignant disease, necrosis
-decreased with viral infection, bone marrow suppression, primary bone marrow disease
Eosinophils
-Increased in allergy, parasitic disease, collagen disease, subacute infections
-Decreased with stress, use of some medications(ACTH, Epinephrine, thyroxin)
Basophils
-Increase with leukemia and following surgery or trauma
-Decreased with allergic reactions, stress, allergy, parasitic disease, use of corticosteroids
Lymphocytes
-Increased with infectious mononucleosis, viral and some bacterial infections, hepatitis
-Decreased with aplastic anemia, SLE, immunodefficiency includung AIDS
Platelet count
-Increased in malignancy, myeloproliferative disease, rheumathoid arthritis, and postoperatively; about 50% of patients with
unexpected increase in platelet count will be found to have malignancy
-Decreased in throbocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy
Clotting Time
-Types:Proyhrombin Time, Partial Thromboplastin Time, Activated Partial Thromboplastin Time
Bleeding Time
- 1 to 9 minutes
Nuetrophils 64 35-70
Lymphocyte 36 20-35
Eosinophils 0-4
Blood Type
Clotting Time 5-10 minutes
NOTE!- Laboratory values may vary according to the techniques used in different laboratories.
URINALYSIS
Date: August 2,2010
Macroscopic Examination
Bacteria: Few
Date: August 03
Time: 8:10 AM
PLT Flags
WBC: 4.4 L 103 /mm 3 < 5.0-10.0 > MCV: 82 Um3 < 80- 47 >
RBC: 4.46 103 /mm3 < 4.20-6.30 > MCH: 25.9 L Pg < 26.5-33.5 >
HGB: 11.6 L g/dL < 12.0-18.0 > MCHC: 31.6 g/dL < 31.5-35.0 >
PLT: 417 103 /mm3 < 142-424 > MPV: 6.5 Um3 < 6.5-11.0 >
WBC Flags
% LYM: 56.3 H % < 17.0-48.0 > # LYM: 2.4 103/mm3 <1.2-3.2 >
%MON: 4.1 % < 4.0-10.0 > #MON: 0.1 L 103/mm3 < 0.3-0.8 >
Lymphocytes
-Increased with infectious mononucleosis, viral and some bacterial infections, hepatitis
-Decreased with aplastic anemia, SLE, immunodefficiency includung AIDS
Monocytes
-Increased with viral infections, parasitic disease, collagen and hemolytic disorders
PLT Flags: G2
WBC: 6.9 103/mm3 < 5.0- 10.0 > MCV: 82 Um3 < 80-97 >
RBC: 4.65 103/mm3 < 4.20-6.30 > MCH: 26.1 Lpg < 26.5-33.5 >
HGB: 12.1 g/Dl < 12.0-18.0 > MCHC: 31.9 g/dL < 31.5-35.0 >
HCT: 37.9 % < 37.0-51.0 > RDW: 13.0 % < 10.0-15.0 >
PLT: 223 103/mm3 < 142-424 > MPV: 6.6 Um3 < 6.5-11.0 >
PCT: .147 % < .100- .500 > PDW: 11.4 % < 10.0-18.0 >
WBC Flags
% LYM: 53.6 H % < 17.0-48.0 > # LYM: 3.6 H 103/mm3 < 1.2-3.2 >
% MON: 8.1 % < 4.0-10.0 > #MON: 0.5 103mm3 < 0.3-8.0 >
% GRA: 38.3 L % < 43.0-76.0 > #GRA: 2.8 103/mm3 < 1.2-6.8 >
Time: 9:54 PM
PLT Flags
WBC: 12.0 H 103/mm3 < 5.0-10.0 > MCV: 80 Um3 < 80-97 >
RBC: 4.18 L 103 /mm3 < 4.20-6.30 > MCH: 26.2 L pG < 26.5-33.5 >
HGB: 11.0 L g/dL < 12.0-18.0 > MCHC: 32.7 g/dL < 31.5-35.0 >
HCT: 33.5 % 103/mm3 < 37.0-51.0 > RDW: 13.2 % < 10.0-15.0 >
PLT : 354 103/mm3 < 142-424 > MPV: 6.2 L Um3 < 6.5-11.0 >
PCT: .219 % < .100-.500 > PDW: 11.5 % < 10.0-18.0 >
WBC Flags: G1 G2
%LYM: 57.5 H % #LYM: 6.9 H 103/mm3 < 1.2-3.2 >
IgM
-Increased Waldenstroms Macroglubenemia, parasitic infections, hepatitis
-Decreased in Aggamaglubenemias, some IgG and IgA myelomas, chronic lymphatic luekemia
IgG
-Increased in IgG myeloma, following hyperimmunization, autoimmune disease states, chronic infections
-Decreased in congenital and acquired hypogammaglubenemia, IgA myelomas, Waldenstroms macroglobunemia, some malabsorption
syndrome, extensive protein loss
08-04-2010
8:10 AM
08-05-2010
08-05-2010
9:30AM
> For repeat RBC, with APC now
>For repeat Dengue Line Test
Positive MP rashes in all extrenities
Positive fever, chills
IgM positive-Dengue Test
>Shift IVF to D5LR 1L at 70cc/hr
>Ascorbic Acid 100mg/5ml 2x a day
>Please monitor V/S including BPq4 hrs.
>Cetirizine 25mg/5ml, 1ml q 12 hrs.
>for repeat CBC with APC at 10 PM At 8PM, vital signs were taken and recorded. Patient is
afebrile T-36.8. I and O was measured.
9:00PM At 10PM, patient is febrile. Paracetamol was given as
>12Kgs. ordered by ROD. TSB was done continuously till
>Paracetamol 120mg IV now temperature subsided;SO was instructed to do so if
>Oxygen inhalation at 6 cpm temperature exceeds 37.8. clothings were loosened to
>For Hgb, Hct, APC at 2PM facilitate further relief from heat. Provided a cool and
>Increase IVF rate to 80cc/hr. quiet environment. Oxygen inhalation via facemask
Positive chills was administered by ROD.
Positive noted circumval cyanosis Patient was kept rested and comfortable. Needs were
Negative seizure attended and was endorsed accordingly.
08-06-2010
MP rashes
Fever 39.8