1. D NGUE WORKSHOP 2015 E
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2. OPD – CASE 2
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3. History 33/ Indian /man Presented with fever Myalgia and arthralgia
Went to KK on Day 2 of fever
FBC : Wbc 9.4 Hb Hct 39 Plat 241
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4. FEVER CLERKING SHEET
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5. When to suspect dengue
Fever with two or more of the following manifestations:
- headache
- retro-orbital pain
- myalgia
- arthralgia
- rash
- haemorrhagic manifestations
- leukopenia/ Thrombocytopenia
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6. You are the doctor in charge
What would you do?
Dengue combo rapid test :
NS1: Positive , Dengue Ig M : negative
Look for warning signs
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7. Dengue NS1
The NS1 gene product is a glycoprotein produced by all flaviviruses
NS1 antigen appears as early as day 1 after the onset of fever and declines to undetectable levels after day 5–6.
It is a tool to facilitate early detection of dengue
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8. Dengue Ig M
Negative in early febrile phase, a positive result indicates a recent infection, not the acute infection
Becomes positive towards defervescence and increasingly more positive;
Day 7 of illness almost 80% positive; remains detectable for another 2-3 month
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9. Warning signs Listen : Mucosal bleed ( 4 symptoms) Abd pain
Persistent vomiting
Restless/lethargy
Examine : Tender enlarged liver
( 2 signs) Third space loss
Lab : ( 1 lab) increase in HCT accompanied by rapid decrease in Platelet count
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10. What would you do next ?
Assess for hydration status/ BP/PR/ Pulse volume/ CRT/ RR/
Physical Exam
Do not for get to : Notify Dengue
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11. Dengue Clerking Sheet
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12. No warning signs, Vital signs are stable
No vomiting, no abdominal pain
BP 120/80mmHg, PR 90 /min
RR 16/min
No rashes , no petechiae
Lung : clear
PA : soft , no ascites, no tenderness
No warning signs, Vital signs are stable
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13. Desided to send patient home
Prescribe symptomatic therapy
Advise patient to return to clinic if :
fever persists more ≥ 3days or
develops warning signs or
unable to take orally
What is your advice to patient ?
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14. PNEUMONIC : DENGUE D- daily monitoring of patient's status
E- encouraging intake of oral fluids
N- note for any warnings or signals (persistent vomiting, severe abdominal pain, restlessness, irritability, platelet count, bloated abdomen)
G- give symptomatic treatment (avoid aspirin/NSAID)
U- use mosquitoe screens, insect sprays, repellant
E- early consultation is advised if you have doubts
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15. Plan of management If admission is not indicated
Daily or more frequent follow up is necessary especially from day 3 of illness onwards until the patient becomes afebrile for at least hours without antipyretics
Refer to Home Care Advice Leaflet for Dengue Patients.
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17. HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS
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18. ID HSB 2015

19. Day 5 : still febrile Still poor appetite but able to drink
No vomiting , no abdominal pain
No other complaints
T 38 C,BP 108/80mmHg, PR 90/min
Lung : Clear, PA :no tenderness
Day 5: Hb Hct Platelet Wbc 4.07
Day 2: Hb Hct Platelet Wbc 9.4
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20. What would you do ? Day 5 illness , still in febrile phase
No warning signs
VS stable
HCT : increasing, Platelet : dropping
But entering defervescent phase soon!
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21. ID HSB 2015

22. Plan of management If admission is indicated
Stabilise the patient at primary care before transfer (refer to intravenous fluid regime)
Communicate with the receiving hospital: Emergency & Trauma Department AND/Or Medical Department before transfer
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23. What is your diagnosis T 38 C,BP 108/80mmHg, PR 90/min
Lung : Clear, PA :no tenderness
Day 5: Hb Hct Platelet Wbc 4.07
Day 2: Hb Hct platelet Wbc 9.4
Day 5 : Alb 32 ALT 79 AST 167
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24. What is your diagnosis? Day 5 illness, febrile phase
with warning signs, vital signs are stable, mild transaminitis
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25. What are the warning signs?
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26. How much fluid to give?
Fluid management in dengue with warning signs
Obtain baseline HCt
IVD 5-7mls/kg/hr for 1 to 2 hours, then
Reduce to 3-5mls/kg/hr for 2 to 4 hours, and then
Reduce to 2-3mls/kg/hr or less according to clinical response and HCT
If clinical parameters worsening and Hct is rising, increase the rate of infusion
5,3,2
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27. Dengue with alarm signs + but haemodynamically stable : 5/3/2 regime OR 7/5/3 regime
5mg/kg/H : 1-2hrs ml/kg/H
3ml/kg/H: 2-4 hrs ml/kg/H
2ml/kg/H : till review ( 2-4H) ml/kg/H
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28. IVD 5ml/kg : 300ml/Hour for 1 hour  review
Weight 60kg
IVD 5ml/kg : 300ml/Hour for 1 hour  review
IVD 3ml/kg : 180ml/Hour for 2hours review
IVD 2ml/kg : 120ml/Hour for 2-4hoursreview
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29. 3 hours later , at completion of 5/3 regime….
BP 110/80mmHg, PR 110/min ( weak )
T 37 C
Lung :clear
Dengue Fever , day 5 illness,
in critical phase
In compensated shock
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30. What would you do ? Refer to ED and medical team on call
2. Run fluid 10ml/kg over 1 hour, and assess again
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31. Dengue CPG :
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32. This is to facilitate rapid response to critically ill patient.
However, if patient is ill, (i.e : in compensated or decompensated), pre-empting a deterioration that may require resuscitation, you should inform BOTH Emergency Department and Medical Department Physician prior to transfer.
This is to facilitate rapid response to critically ill patient.
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33. THANK YOU ND
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