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Group 6 gcp
 

Group 6 gcp

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  • Dengue may be divided into 3 phasesFebrile phase Usually lasts 2-7 day. Mild hemorrhagic manifestations like petechiae & mucosal membrane bleeding may be seen. Earliest lab abnormality in CBC is a progressive decrease in WBCCritical phaseDefervescence occurs on day 3-7 (temp 37.5-38C or less). IF patient improves = Dengue w/o Warning Signs; IF patient deteriorates = Dengue w/ Warning Signs. Period of clinically significant plasma leakage usually lasts 24-48 hours.Recovery phaseBy way of lymphatics in the next 48-72 hours
  • Dengue may be divided into 3 phasesFebrile phase Usually lasts 2-7 day. Mild hemorrhagic manifestations like petechiae & mucosal membrane bleeding may be seen. Earliest lab abnormality in CBC is a progressive decrease in WBCCritical phaseDefervescence occurs on day 3-7 (temp 37.5-38C or less). IF patient improves = Dengue w/o Warning Signs; IF patient deteriorates = Dengue w/ Warning Signs. Period of clinically significant plasma leakage usually lasts 24-48 hours.Recovery phaseBy way of lymphatics in the next 48-72 hours
  • Dengue is an all-year round disease in the Philippines. According to the Department of Health, in 2010, all regions reported cases of dengue and several outbreaks were reported in provinces and municipalities. The cases totalled to 135,355, which is 135% higher compared to 57, 636 cases in 2009. At present, there were 102,192 cases of the denguefrom January 1 to August 24 this year, which is 7.61 percent lower than the 110,611 cases recorded in the same period last year.
  • The Aedesaegypti mosquito is the main vector that transmits the viruses that cause dengue. The viruses are passed on to humans through the bites of an infective female Aedes mosquito, which mainly acquires the virus while feeding on the blood of an infected person.Once infected, humans become the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of an infected person for 2-7 days, at approximately the same time that the person develops a fever. Patients who are already infected with the dengue virus can transmit the infection via Aedes mosquitoes after the first symptoms appear (during 4-5 days; maximum 12).In humans recovery from infection by one dengue virus provides lifelong immunity against that particular virus serotype. However, this immunity confers only partial and transient protection against subsequent infection by the other three serotypes of the virus. Evidence points to the fact that sequential infection increases the risk of developing severe dengue. The time interval between infections and the particular viral sequence of infections may also be of importance.
  • After subcutaneous injection of the virus into the skin, released viral particles may infect nearby cells (thought to be predominantly monocytes or dendritic cells (DCs)) or activate resident immune cells such as mast cells. A local inflammatory response to DENV in the skin prompts the recruitment of leukocytes from the vasculature, including natural killer (NK) cells and T cells, which promote the killing of virus-infected cells at the site of injection. DENV is thought to then travel to draining lymph nodes via lymphatic vessels to establish systemic infection. These localized inflammatory responses occur many days before there are any signs of severe infection.
  • “Instead of confining patients in a hospital facility, parents and caregivers can practice the D.E.N.G.U.E. strategy. D.E.N.G.U.E. stands for D - daily monitoring of patient’s status, E - encourage intake of oral fluids like oresol, water, juices, etc, N – note any dengue warning signs like persistent vomiting and bleeding, G – give paracetamol for fever and NOT aspirin, because aspirin induces bleeding, U – use mosquito nets and E – early consultation is advised for any warning signs”, Health Secretary Enrique Ona said.DOH launches ‘D.E.N.G.U.E.’ strategyRepublic of the PhilippinesDepartment of Healthhttp://www.doh.gov.ph/doh_launches_dengue.html
  • UST Pharma Match 2012http://www.pchrd.dost.gov.ph/index.php/2012-05-23-07-46-36/2012-05-24-00-01-32/5296-tawa-tawa-contains-active-ingredients-that-may-help-dengue-hemorrhagic-fever-dhf-patients-studyHistopathological Examination Tissue examination of the liver and spleen provided further evidence of thrombocytopenia as induced by ethanol and the curative effects of the E. hirtadecoction. Liver damage, which can result from chronic intake of ethanol, leads to an increase in the blood pressure of the portal veins which will impede the flow of blood out of the spleen. This leads to the platelets being sequestered in the spleen. [26] The dilation of the sinusoids of these organs are often the result of poor venous outflow. The ethanol only group was marked with dilations that are 2+ and 3+ while the ethanol + E. hirtagroup and the control group only had the presence of 1+ and 2+ dilations
  • http://www.cdc.gov/media/releases/2012/p0620_dengue_test.html
  • http://www.cdc.gov/media/releases/2012/p0620_dengue_test.htmlhttp://www.cdc.gov/dengue/clinicalLab/laboratory.html
  • http://www.cdc.gov/media/releases/2012/p0620_dengue_test.htmlhttp://www.cdc.gov/dengue/clinicalLab/laboratory.html
  • Ona also reiterated that the most effective way to prevent and fight dengue is still by practicing the DOH’s 4-S strategy consisting of Search and destroy, Self-protective measures, Seek early treatment and Say no to indiscriminate fogging.DOH launches ‘D.E.N.G.U.E.’ strategyRepublic of the PhilippinesDepartment of Healthhttp://www.doh.gov.ph/doh_launches_dengue.html
  • http://www.epa.gov/pesticides/insect/repellency-awareness.html
  • http://www.pchrd.dost.gov.ph/index.php/2012-05-23-07-46-36/2012-05-24-00-01-32/5055-dengue-vaccine-may-be-available-in-2014
  • http://region1.dost.gov.ph/index.php?option=com_content&view=article&id=156:dengue-mosquito-ol-trap-a-local-technology-that-worksq&catid=65:latest-news&Itemid=93
  • http://www.dost.gov.ph/index.php?option=com_content&view=article&id=1294:dost-launches-dengue-alert-website-&catid=1:latest&Itemid=150http://dengue.pchrd.dost.gov.phhttp://oltrap.pchrd.dost.gov.phhttp://www.healthmap.org/dengue/en/

Group 6 gcp Group 6 gcp Presentation Transcript

  • Acute fever, body malaise and rashes in a 25 year old male Group case presentation 6A Joya, Jeb Reinard Kalaw, Maria Natalia Kho, Beatriz Barbara Kimura, Akemi King, Emmanuel Koa, Daryl Lacuna, Dan Paulo Lalusis, John Kelvin Lao, Nicole Mae Laxamana, Jack Rene Module 4 Group 6 3B Med 6B Laxamana, Michael Laygo, Richard Joseph Lee, Andria Lee, Nica Kristine Lerma, Joshua Dave Libiran, Jonika Maris Lim, Janine Abigail Lim, Jerald Garvin Lim, Joseph Michael
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Objectives • To present a case of a patient with acute fever • To discuss differential diagnoses • To discuss Dengue infection – – – – – Epidemiology Pathophysiology Clinical manifestations Treatment & management Updates on diagnosis & treatment
  • GCP: Acute fever, body malaise & rashes in a 25 year old male History 6A Kalaw, Maria Natalia & Kimura, Akemi 6B Laxamana, Michael & Laygo, Richard Joseph
  • GCP: Acute fever, body malaise & rashes in a 25 year old male General Information Name of Patient: J.R.P Address: R. Papa, Manila Age: 25 years old Birthday: July 01, 1988 Sex: Male Civil Status: Single Religion: Roman Catholic Nationality: Filipino Educational Attainment: College level (2nd yr. B.S. in Nursing) Occupation: unemployed Date Admitted: November 3, 2013 Bed No. 210 C Date of Interview: November 8, 2013 (Hospital Day 6) Informant: Patient Informant Reliability: 90%
  • GCP: Acute fever, body malaise & rashes in a 25 year old male A 25 year old male Chief complaint: Fever • • • chills, fever (39oC), body malaise Self medicated Paracetamol (Biogesic) 500mg/tab 1tab PO q4h Amoxicillin 500mg/cap 1cap PO 13 hours PTA • • • • fever (39.1 - 39.9oC), sore throat, vomiting after meals, anorexia, headache 5/10, myalgia on upper extremities 6/10, knee arthralgia 4/10 2 hours PTA • fever 39.8oC, flushed face, red eyes, dry lips 2 days PTA Admission November 03, 2013
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Past Medical History A 25 year old male • BIRTH AND DEVELOPMENTAL HISTORY: unrecalled • CHILDHOOD ILLNESS/HOSPITALIZATIONS: none • ADULT ILLNESS/HOSPITALIZATIONS: none • SURGERIES: none • INJURIES/ACCIDENTS: none • TRANSFUSIONS/REACTIONS: none • ALLERGIES: none • IMMUNIZATION: unrecalled
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Family History (+) Asthma: Father, brother (-) Thyroid problems, DM (-) Hypertension & cardiovascular diseases (-) Cancer Personal and Social History • • • • • Smoking: 0.75 pack years (5 sticks per day since 2010) Occasional social alcoholic beverage drinker (wine, beer, hard drinks) No illicit drug use Nutrition – No eating difficulties, has good appetite – High salt diet – Usually eats a generous serving of vegetables & fruits Sleep Pattern – No difficulty in sleeping – Sleeps for about 9-10 hours a day, no naps in between
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Personal and Social History • • • • • • Marital status Single Living arrangement/ Family structure Has 2 older brothers and sister; youngest among siblings Lives alone, rents an apartment unit beside older brother’s unit Support/secondary gains Mother, older brother and sister-in-law are the primary caregivers. Older brother supports patient financially Employment history/Job satisfaction 2010 Crew at McDonald’s UAE 2011 Promoted to Supervisor in McDonald’s UAE 2013 February – finished contract Sexual history Had 1 sexual partner (Filipina OFW, UAE, 2012) Significant life events, deaths, hardships 2007 death of father due to car accident denied having financial hardship thereafter
  • GCP: Acute fever, body malaise & rashes in a 25 year old male REVIEW OF SYSTEMS General Conscious, coherent, not in respiratory distress Skin (-) pigmentation, (-) pruritus, (-) jaundice, (-) pallor HEENT (+) blurring of vision, (-) ear discharge, (-) ear pain, (-) epistaxis, (-) gum bleeding, (-) hoarseness, (-) ulcers Cardiovascular (-) palpitations, (-) cyanosis, (-) chest pain, (-) PND, (-) orthopnea, (-) easy fatigability Respiratory (-) cough, (-) colds, (-) exertional dyspnea Gastrointestinal (-) constipation, (-) diarrhea, (-) melena Genitourinary (-) urgency, (-) hematuria, (-) oliguria, (-) dysuria, (-) nocturia, Musculoskeletal (-) swelling, (-) Inflammation Neurologic (-) seizures, (-) tremors, (-) sleep disturbance, (-) alterations of mood Hematologic (-) easy bruisability, (-) anemia Endocrine/Metabolic (-) polyphagia, (-) polyuria, (-) polydipsia, (-) heat/cold intolerance Psychiatric (-) depression, (-) hallucinations
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Physical Examination 6A Kalaw, Maria Natalia & Kimura, Akemi 6B Laxamana, Michael & Laygo, Richard Joseph
  • GCP: Acute fever, body malaise & rashes in a 25 year old male General survey On Admission (November 3, 2013) Upon PE (November 8, 2013) •Conscious, coherent, awake •Conscious, coherent, awake •GCS 15 •GCS 15 •Ambulatory •Ambulatory •not in respiratory nor cardiac distress •not in respiratory nor cardiac distress •oriented to time, place and person •oriented to time, place and person • cooperative, neutral mood, broad affect • cooperative, neutral mood, broad affect • no agitation • no agitation • judgment and insight intact • judgment and insight intact • intact memory for recent and remote events • intact memory for recent and remote events
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Vital Signs & Anthropometrics On Admission (November 3, 2013) Upon PE (November 8, 2013) •BP = 110/80 mmHg (Sitting) •BP = 100/80 mmHg (Sitting) • PR = 107 bpm, regular • PR = 65 bpm, regular • RR = 20 breaths per min, regular • RR =19 breaths per min, regular • Temp 38.7 °C (Axillary) • Temp 36.0 °C (Axillary) •Height = 165 cm •Height = 165 cm •Weight = Kg •Weight = 53 Kg •BMI = 18.5 (Normal) •BMI = 18.5 (Normal)
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Skin On Admission (November 3, 2013) Upon PE (November 8, 2013) •(-) petechiae •(+) petechiae on both lower extremities • Warm, moist • Warm, moist • no facial flushing • no facial flushing • no palmar erythema • no palmar erythema • pink nail beds, no clubbing • pink nail beds, no clubbing
  • GCP: Acute fever, body malaise & rashes in a 25 year old male HEENT On Admission (November 3, 2013) Upon PE (November 8, 2013) • Head : round, symmetrical & no deformities, no lesions or masses • Head : round, symmetrical & no deformities, no lesions or masses hair is black, ample in volume & with smooth texture Eyes : no ptosis & exophthalmos pink palpebral conjunctiva anicteric sclera pupils 2-3mm equally reactive to light, (+) ROR Eyes : no ptosis & exophthalmos pink palpebral conjunctiva anicteric sclera pupils 2-3mm equally reactive to light, (+) ROR •Ears : no ear deformities and tenderness, gross hearing intact, intact tympanic membranes, nonhyperemic external auditory canals •Nose: no alar flaring, no nasal discharge •Ears : no ear deformities and tenderness, gross hearing intact, intact tympanic membranes, nonhyperemic external auditory canals •Nose: no alar flaring, no nasal discharge • Mouth: pinkish lips, moist buccal mucosa, no cyanosis •no oral ulcers •septum at midline •non-congested nasal turbinates •Throat: non hyperemic posterior pharyngeal wall •moist nasal mucosa •tonsils not enlarged • Mouth: pinkish lips, moist buccal mucosa, no cyanosis •Tongue not deviated •no oral ulcers •uvula in midline •Throat: non hyperemic posterior pharyngeal wall •Supple neck, no limitation in motion •tonsils not enlarged •no palpable cervical masses and lymph nodes •Tongue not deviated •uvula in midline •Supple neck, no limitation in motion •no palpable cervical masses and lymph nodes
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Thorax/Lungs On Admission (November 3, 2013) Upon PE (November 8, 2013) •Symmetrical chest expansion •Not in respiratory distress •no tenderness upon palpation of chest •normal tactile and vocal fremiti on all lung fields •no adventitious breath sounds on all lung fields •symmetrically resonant on all fields •Symmetrical chest expansion •no chest deformities •trachea midline •regular pattern of breathing •no use of accessory muscles, SCM not prominent •no tenderness upon palpation of chest •normal tactile and vocal fremiti on all lung fields •no adventitious breath sounds on all lung fields •symmetrically resonant on all fields
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Chest/Heart On Admission (November 3, 2013) Upon PE (November 8, 2013) •JVP 3 cm at 30 degrees •JVP 3 cm at 30 degrees •carotid artery pulse with rapid upstroke and gradual downstroke •carotid artery pulse with rapid upstroke and gradual downstroke, •adynamic precordium •adynamic precordium •no murmurs, no thrills, heaves or lifts •no murmurs, no thrills, heaves or lifts •S1 > S2 at apex, S2 > S1 at base, no S3 or S4 • apex beat 11.5 cm from sternum at 6th ICS, on the Left, 1 fingerbreadth soft in •(+)2 on radial, dorsalis pedis, posterior characteristic tibialis, brachial and popliteal pulses • S1 > S2 at apex, S2 > S1 at base, no S3 or S4 •(+)2 on radial, dorsalis pedis, posterior tibialis, brachial and popliteal pulses
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Abdomen/Gastrointestinal On Admission (November 3, 2013) Upon PE (November 8, 2013) •abdomen is flat and symmetrical •abdomen is flat and symmetrical •umbilicus in midline •no visible pulsations and peristalsis •normoactive bowel sounds •umbilicus in midline and inverted •tympanitic at all quadrants •normoactive bowel sounds, no borborygmi •No tenderness on light & deep palpation •tympanitic at all quadrants •No tenderness on light & deep palpation •Liver span = 9 cm Right MCL •Traube’s space is not obliterated
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Genitourinary On Admission (November 3, 2013) •(-) CVA tenderness Upon PE (November 8, 2013) •(-) CVA tenderness •non palpable kidneys
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Neurologic exam On Admission (November 3, 2013) Cranial Nerves CN I No anosmia •CN 2 : pupils 2-3 mm ERTL, (+) direct and consensual light reflex on both eyes, corneal reflex intact, (+) accommodation, (-) visual field defect, (-) ptosis •CN 3 4 6: EOMs full & equal • No nystagmus, no drooping of eyelids •CN 5: no sensory deficit on the left of face •CN 7: Can clench teeth, can smile, can frown •CN8 : Gross hearing intact •CN 9 10: (+) gag reflex, Uvula midline on phonation •CN 11: Can shrug both shoulders •CN 12: No deviation of the tongue on protrusion Upon PE (November 8, 2013) Cerebrum: •GCS 15 (E4 V5 M6) •Conscious, coherent, awake •Oriented to time, place & person •Follows commands Cerebellum • Able to do finger-to-nose test & alternate pronation-supination test Cranial Nerves CN I No anosmia •CN 2 : pupils 2-3 mm ERTL, (+) direct and consensual light reflex on both eyes, corneal reflex intact, (+) accommodation, (-) visual field defect, (-) ptosis •CN 3 4 6: EOMs full & equal • No nystagmus, no drooping of eyelids •CN 5: no sensory deficit on the left of face •CN 7: Can clench teeth, can smile, can frown •CN8 : Gross hearing intact •CN 9 10: (+) gag reflex, Uvula midline on phonation •CN 11: Can shrug both shoulders •CN 12: No deviation of the tongue on protrusion
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Salient Features 25 y.o. Male Subjective • Fever, chills • body malaise • sore throat, vomiting after meals, anorexia • headache 5/10 • myalgia on upper extremities 6/10, • knee arthralgia 4/10 Objective • Vital signs BP: 100/80 PR: 65 bpm RR: 19 cpm Temp: 36 oC
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Initial Impression Acute Viral Infection
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Differential Diagnosis 6A King, Emmanuel & Lao, Nicole Mae 6B Lee, Andria & Lee, Nica Kristine
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Patient Fever 39oC Chills body malaise Sore throat Vomiting after meals anorexia headache myalgia, arthralgia Rashes on both lower extremities Chikungunya Virus Infection Fever(38oC-39oC) Chills Myalgias Arthralgias Headache Photophobia Cough Coryza Pharyngitis Anorexia Nausea Vomiting Fatigue Malaise Splenomegaly Dark urine/clay-colored stools before the onset of jaundice Exposure to endemic areas/ contaminated food/water Influenza Acute Fever not responding to antibiotic therapy Headache Physical Findings: Conjunctival Suffusion Pharyngeal erythema w/o exudate Muscle tenderness Dullness on lung percussion Rales on lung auscultation Rash (maculopapular, erythematous, petechial or ecchymotic) Exposure history Rocky Mountain Spotted Fever Fever Abdominal pain Headache Photophobia Vomitting Vertigo Sore throat Meningeal signs Lethargy Somnolence Disoriented/Intellectual deficit Tremors Loss of abdominal reflexes Cranial nerve palsies Hemiparesis Difficulty in swallowing Tick borne Source: Harrison’s Principles of Internal Medicine 18th edition
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Patient Hepatitis A Infection Leptospirosis Dengue Fever Fever 39oC Chills body malaise Sore throat Vomiting after meals anorexia headache myalgia, arthralgia Fever(38oC-39oC) Chills Myalgias Arthralgias Headache Photophobia Cough Coryza Pharyngitis Anorexia Nausea Vomiting Fatigue Malaise Splenomegaly Dark urine/claycolored stools before the onset of jaundice Exposure to endemic areas/ contaminated food/water Acute Fever not responding to antibiotic therapy Headache Fever Headache Weakness Anorexia General body pain (arthralgias, myalgias) Abdominal pain Vomiting Maculopapular rash Sore throat Mild hemorrhagic manifestations (eg, Rashes on both lower extremities Physical Findings: Conjunctival Suffusion Pharyngeal erythema w/o exudate Muscle tenderness Dullness on lung percussion Rales on lung auscultation Rash (maculopapular, erythematous, petechial or ecchymotic) Exposure history petechiae, bleeding gums, epistaxis, hematuria) Lymphadenopathy Mosquito vector Source: Harrison’s Principles of Internal Medicine 18th edition
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Course in the ward 6A Koa, Daryl, Lacuna, Dan Paulo & Lalusis, John Kelvin 6B Lim, Janine Abigail & Lim, Jerald Garvin
  • Day 1 (11/03) Day 2 (11/04) Day 3 (11/05) Day 4 (11/06) Sx Fever, sore throat, Abd. Pain Fever Fever Fever Hgb 132g/L 129g/L 130g/L 141g/L 140g/L Hct 0.38 0.38 0.37 0.40 0.40 WBC 3.10x109/L (N:0.62, L:0.36, Eo:0.02) 2.50x109/L (N:0.69, L:0.31) 1.90x109/L (N:0.46, L:0.51, Mo:0.03) 3.40x109/L (N:0.19, L:0.78, Mo:0.02, Eo:0.01) 5.00x109/L (N:0.17, L:0.79, Mo:0.02, Eo:0.02) PLT 185x109/L 180x109/L 90x109/L 33x109/L 51x109/L Na 135mmol/L 141mmol/L K 3.72mmol/L 3.98mmol/L Crea: 0.93mg/dL ALT: 39.42U/L Other AST: 51.37 U/L ALT: 37.26 U/L Fecalysis: No significant findings Dengue NS1: (+) Rx 0.4 Paracetamol 500mg Tablet IV Fluid (LRS) Esomeprazole 40mg/tab 1 Paracetamol 500mg Tablet prn Paracetamol 500mg Tablet PRN 2 Paracetamol 500mg Tablet PRN 3 Paracetamol 500mg Tablet PRN 4 4 200 0.3 150 0.2 100 0.1 50 0 0
  • Day 5 (11/07) Day 6 (11/08) Rashes Rashes Sx Hgb 137g/L 140g/L 130g/L Hct 0.40 0.39 0.37 WBC 4.80x109/L (N:0.14, L:0.83, Eo:0.03) 4.10/x109/L (N:0.19, L: 0.75,Mo:0.02, Eo:0.04) 4.30x109/L (N:0.16, L:0.77, Mo:0.02,Eo:0.05) PLT 39x109/L 73x109/L 80x109/L Rx 1 0.4 2 3 4 4 Paracetamol 500mg Tablet PRN Cetirizine 10mg Tablet OD 5 6 None 200 6 150 0.3 0.2 100 0.1 50 0 0
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Final Clinical Diagnosis Dengue Infection (with warning signs of abdominal pain, vomiting, lethargy, increased Hct & rapid increase in platelet count)
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Pathophysiology 6A Kho, Beatriz Barbara & Laxamana, Jack Rene 6B Lerma, Joshua Dave & Libiran, Jonika Maris
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Types of Patient Group A Group B Group C • are able to tolerate adequate volumes of oral fluids • pass urine at least once every six hours • do not have any of the warning signs, particularly when fever subsides • with warning signs OR • Without warning signs but with: • co-existing medical conditions • certain social circumstances • severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress • severe hemorrhages • severe organ impairment DOH Revised Dengue Clinical Management Guidelines, 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male WHO. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control, 2009
  • GCP: Acute fever, body malaise & rashes in a 25 year old male FEBRILE PHASE CRITICAL PHASE RECOVERY PHASE Fever Headache Body malaise Myalgia Arthralgia Retro-orbital pain Anorexia Nausea Vomiting Diarrhea Flushed skin Rash Defervescence Resorption of extravasated fluid Hemodynamic status stabilizes Abdominal pain or tenderness Persistent vomiting Clinical signs of fluid accumulation Mucosal bleeding Lethargy; restlessness Liver enlargement DOH Revised Dengue Clinical Management Guidelines, 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male “The incidence of dengue has increased 30-fold over the last 50 years. Up to 50-100 million infections are now estimated to occur annually in over 100 endemic countries, putting almost half of the world’s population at risk.” Philippines: 7th WHO Global Strategy For Dengue Prevention and Control .2012
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Dengue in the Philippines • 1953- first epidemic of severe dengue • Dengue cases: 110,611(2012) vs 102,192(2013) Source: Department of Health (DOH)
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Pathophysiology Human Aedes aegypti DENGUE Mosquito -breed indoors and are capable of biting anyone throughout the day -less susceptible to climatic variations Virus →increases the mosquitoes’ longevity. Source: WHO. Programmes and Projects: Dengue Control. http://www.who.int/denguecontrol/en/
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Viral replication in white blood cells: Cytokine production= IL-1, IL-6, TNF, IFN → Inflammatory response Fever: ↑PGE2 in hypothalamus→↑cAMP→ altered thermoregulatory set point Myalgia: Perivascular mononuclear infiltrates + Lipid accumulation Microbiology Nausea and vomiting: bloodborne emetic stimuli (H1 and 5-HT) Increased endothelial permeability • Rashes/petechiae (pinpoint hemorrhages) • Induced vasodilatation = dopamine and 5-HT release → headache Ashley, L. et.al. Barriers to preclinical investigations of anti-dengue immunity and dengue pathogenesis. Nature Reviews 11, 420–426 (2013)
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Goals of Therapy, Treatment & Management 6A Koa, Daryl, Lacuna, Dan Paulo & Lalusis, John Kelvin 6B Lim, Janine Abigail & Lim, Jerald Garvin
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Treatment and Management • Revised Dengue Clinical Case Management Guidelines • DOH • 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Monitoring – – – – – Temperature pattern Volume of fluid intake and losses Urine output – volume and frequency Warning signs Hematocrit, WBC and Platelets counts Discharge Criteria • ALL of the following must be present  No fever for 48 hours  Improvement in clinical status      Urine output No respiratory distress  Increasing trend of platelet count  Stable hematocrit without IV fluids General well-being Appetite Hemodynamic status Source: DOH A.O. No. 2012-0006, Revised Dengue Clinical Management Guidelines 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Home Care for Dengue • Adequate bed rest • Adequate fluid intake (>5 glasses for average-sized adult or accordingly in children) – Milk, fruit juice (caution with diabetes patient) and isotonic electrolyte solution (ORS) and barley/rice water – Plain water alone may cause electrolyte imbalance • Take paracetamol (not more than 4 grams per day for adults and accordingly in children) • Tepid sponging • Look for mosquito breeding places in and around the home and eliminate them • AVOID: NSAIDs, Acetylsalycylic acid (aspirin), Mefenamic acid, Steroids (If already taking, consult physician) • Antibiotics are not necessary Source: DOH A.O. No. 2012-0006, Revised Dengue Clinical Management Guidelines 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male D.E.N.G.U.E. D aily monitor the patient’s status E ncourage intake of oral fluids like oresol (oral rehydration solution), water and juices N ote any warning signs of dengue like persistent vomiting and bleeding G ive paracetamol to the patient, NOT aspirin as it induces bleeding U se mosquito nets/repellants E arly consultation with doctors for any warning signs Source: DOH A.O. No. 2012-0006, Revised Dengue Clinical Management Guidelines 2011
  • GCP: Acute fever, body malaise & rashes in a 25 year old male •“Although there were small38.9 ± 9.6% phenolic Platelet count increasedof the anti- of hirta by amount Euphorbia • To determine the validity Thrombocytopenia • compound in tawa-tawa, E.59.38in animalmg/kg to Bleeding time improvedof this decoction (100 models ± sufficient was 6.44% thrombocytopenic effect by hirta by oral gavage) induction by ethanol • exertsubnormal platelet counts due Administration of Clotting time improved quality and ethanol. with effect promoting by 46.6 ± 11.3% to quantity • The platelet count (Micros Raynes said. Histopathological Exam Counter), bleeding time platelets,” Mr. – Less method), and clotting ethanol + determined (Duke’s dilated liver sinusoids in time was E. hirta decoction group it won the Because findings, •during theof6the study’s significantHealthanalysisfirst(PNHRS) theliver at GruppoManila last 10 August Histopathological Research System prize in Week held –and spleen held of the PCHRD Sofitel Medica Award Philippine National – No notable difference in spleen Platelet Count 2012. PCHRD – Gruppo Medica Award is given to undergraduate students engaged in herbal medicine research th that have potential • ThisBleeding Time fordue toor commercial applications. (1 week) of was most likely practical the short duration Blood Collection on Day induction of thrombocytopenia may have7caused liver and 14 Clotting Euphorbia hirtaTime insufficient to cause any significant changes Linn. (Euphorbiaceae) “Tawa-tawa” damage but was Histopathological Exam to the spleen.
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Updates on Diagnosis 6A Koa, Daryl, Lacuna, Dan Paulo & Lalusis, John Kelvin 6B Lim, Janine Abigail & Lim, Jerald Garvin
  • GCP: Acute fever, body malaise & rashes in a 25 year old male
  • GCP: Acute fever, body malaise & rashes in a 25 year old male
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Appraisalresults applicable for your patient? Whatthe results also showed that the sensitivity Are were the results? The Are the results of combined diagnostic kitlaboratories and a - Inofcomparison between hospital did not vary a the the study valid? - Given our patient’s presentation and history, Patients were all selected during a Dengue outbreak in 2011 national reference laboratory, the sensitivity, the significantly between the serotypes of performing presented with a history of fever within Selected patients a diagnostic test capableand was Clinical Question least one ofof theimmune status or specificity, PPV the patient’s NS1/IgM/IgG past 7 days with byand NPV theof Dengue early will unaffected at diagnosis following : rash, severe confirming the pain, headache, retro-orbitalwere myalgia, jointearly detection of combination testsof time confirm management capable • -What test cantoutilize to betweenpains, bleeding of by the interval selected, clinical a onset contribute I an optimal with aof fever of 10 Patients were randomly maximum Dengue infection sample collection diagnosis of Denguehospital per week use of hospitalized patients per in my patient? the patient,and avoid unnecessary and patients were - AllWords: Dengue, twice (early and late), with early the Diagnosis • -Keyoptimal performanceRapid tests require adequate antibioticsbysampled of drugs/ancillaries, limiting and otherisolation, HIA and MAC-ELISA, samples tested PCR, viral training and quality assurance as HIA and MAC-ELISA while late samples were tested with onlythere was a patient expenses in the process. significant difference in the values between hospital laboratories and the national reference laboratory.
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Updates on Prevention 6A Koa, Daryl, Lacuna, Dan Paulo & Lalusis, John Kelvin 6B Lim, Janine Abigail & Lim, Jerald Garvin
  • GCP: Acute fever, body malaise & rashes in a 25 year old male
  • GCP: Acute fever, body malaise & rashes in a 25 year old male The graphic will identify the type of pest the product is expected to repel & the amount of time the repellent will be effective. Source: United States Environmental Protection Agency http://www.epa.gov
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Technological Initiatives
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Technological Initiatives • Dengue Vaccine – Final stage of clinical development – Sanofi Pasteur dengue vaccine • Only vaccine entered Phase III clinical study • Mexico, Colombia, Honduras, Puerto Rico, Peru, Vietnam, Singapore, Australia, Thailand and the Philippines • Initial data showed very satisfactory results in terms of safety profile and balance immune system response to the four dengue serotypes (serotype 1,2,3 and 4) among children, adolescents and adults tested Source: http://www.pchrd.dost.gov.ph
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Technological Initiatives • Ovicidal Larvicidal Trap – Ordinary tin can painted black – Strip of lawanit board – Solution Source: http://www.pchrd.dost.gov.ph
  • GCP: Acute fever, body malaise & rashes in a 25 year old male Technological Initiatives Dengue Vector Surveillance websites – Mosquito population nationwide – Dengue incidence, other mosquito-related facts Source: www.cdc.gov; www.dost.gov.ph
  • Technological Initiatives Biologic Agents – Larvivorous fishes • Gumbusia affinis, a fresh water fish species, commonly known as “gambusia”, “kataba”, “bubundat” or “mosquito fish,” • Poecilia reticulate, commonly known as “guppy fish,” can also consume about 80 to 100 mosquito larvae per day – Predatory copepods like water bugs • Diplonychus indicus – Sterile male mosquito Source: http://www.dost.gov.ph
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