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Family Case: Dengue Hemorrhagic Fever

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Dengue Hemorrhagic Fever

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Family Case: Dengue Hemorrhagic Fever

  1. 1. Department of Family & Community Medicine Perpetual Succour Hospital BLEEDING LOVE FAMILY CASE PRESENTATION 1st Year Resident Crisbert I. Cualteros, M.D. Postgraduate Interns Alaba, Clevan Teresita Encong, Aubrey Taghoy, Josie Mae Tancongco, Ziphora Tingcang, Marvic Mae Nisnisan, Arvin
  2. 2. Objectives: General Objective: To present a case of Dengue Hemorrhagic Fever Specific Objectives: 1)To discuss the family profile of Curaraton- Tundag Family 2)To present the index case with Dengue Hemorrhagic Fever 3)To discuss briefly DHF 4)To establish the family diagnosis, intervention and recommendation using family assessment tools
  3. 3. Family Profile
  4. 4. THE HOUSE • 16 x 19 feet house • 1 bedroom • With CR inside be dro o m
  5. 5. LIVING AREA
  6. 6. DINING AREA AND KITCHEN DINING AREA KITCHEN AREA
  7. 7. FAMILY LIFE LINE 1988: “Basta Driver – Sweet Lover!” • Ruben worked as a family driver at a well-known subdivision in Cebu City where Magdalena was a nanny. Magdalena was the one who brought the employer’s daughter to school and it was Ruben who drove them. Friendship bloomed between the two. Magdalena was always excited by these moments, as well as Ruben. This continued for a year.
  8. 8. May 1989: “CARELESS WHISPER” • Ruben and Magdalena developed deeper feelings for each other so they decided to live together. For 7 months, they stayed in a rented house near their workplace. • Ruben transferred and got another job, still as a family driver. Magdalena supported Ruben’s decision.
  9. 9. 1990: “When 2 Become 1” • Ruben and Magdalena’s relationship became more intimate and finally, Ruben asked Magdalena’s hand in marriage. • Opportunity came and Magdalena resigned from being a nanny and transferred to MEPZA (in a tailoring company) and worked there for 6months.
  10. 10. 1991: “Confused??? Pag-sure oi!” • After her contract expired, Magdalena transferred to Mandaue to work at a food factory (Cheese Curls) as a production worker. • Due to economic reasons, Magdalena transferred again to a number of other companies in search of greener pastures. (Accessories maker for 3 years, room attendant for 4 years at a pension house)
  11. 11. Sept 2002: “Oh Baby, Baby” • Because of their undying love, Mary Eve was born after twelve years of their living together. Oct 2004: “Baby One More Time” • Not too long after, their second child was born and they named him Robert John.
  12. 12. Economic Profile Total Monthly Income 8,000 – 8,500 PERCENT ALLOCATION Total Monthly Expenses: 8,200 96.5% Food: 4,500 – 5,000 53% Electricity: 700 8.3% Water: 400 4.7% Medicine: 800-900 10.5% Miscellaneous: 1,300 16% Savings 300 3.5%
  13. 13. Curaraton-Tundag Family • Nuclear Family • Externally Patriarchal • Internally Matriarchal • 4 members
  14. 14. Magdalena • 40 years old • Mother • Housewife • Non-smoker • Non-alcoholic beverage drinker • 1993- Cardiomegaly • Unrecalled meds taken for a month
  15. 15. Ruben • 45 years old • Father • Shipper/ delivery man • Occ’l alcoholic beverage drinker • Smoker for >20years, 3 sticks/day • 1990-Psoriasis, took MX3 capsule TID, Clobetasol propionate (Dermovate) + Petroleum jelly BID, Unrecalled anti-allergy PRN
  16. 16. Mary Eve • 7 years old • Grade 1 pupil • Colegio Del Santo Nino • Non-asthmatic • No illness
  17. 17. Robert John • 4 years old • Male child • Index patient • Nursery pupil • No medical problem
  18. 18. Prenatal, Natal& Postnatal History: • Fullterm • NSD at a Lying-in Clinic • Birth Rank: 2/2 • No birth complications • Breastfed up to 3 months then mixed fed • Weaned at 5 months • Complete primary immunization at BHC
  19. 19. Past Medical History • No medical problem • No allergies • Previous Hospitalization: none • HFD: HPN, DM & BA
  20. 20. History of Present Illness: • 2 days PTA, fever noted (38 oC), was given Paracetamol with temporary relief. No consult done. Condition was tolerated. • Night PTA, above condition was associated with nausea and vomiting, consult with AP, was given Metoclopramide and Cefadroxil.
  21. 21. History of Present Illness: • CBC was taken which showed thrombocytopenia. • Persistence of above condition associated with vomiting of brownish-colored vomitus and abdominal pain prompted admission.
  22. 22. Physical Examination • Gen Survey: Patient was irritable, afebrile, not in respiratory distress with the ff v/s: BP:90/60 HR:139 RR:34 T:37.4*C Wt : 15 kgs • Skin: flushed, warm with good turgor
  23. 23. Physical Examination • HEENT: Pink palpebral conjunctivae, anicteric sclerae, no epistaxis, dry lips and tongue with minimal gum bleeding • Neck: supple, no LAD • C/L: equal chest expansion, harsh breath sounds, no rales, no wheeze • CVS: adynamic precordium, distinct heart sounds, no murmur
  24. 24. Physical Examination • Abd: flat, normoactive bowel sounds, soft, with mild epigastric area tenderness • GUT: negative KPS bilaterally • Ext: warm, CRT<2 secs, strong peripheral pulses • CNS: WNL
  25. 25. IMPRESSION DENGUE HEMORRHAGIC FEVER STAGE 1, GRADE 2
  26. 26. On admission: • IVF started, 300 cc was given as MFD(20cc/kg), then regulated to 70 cc/hr (4.6cc/kg) • Additional Labs: u/a, Na, K, BT B(+), Creatinine • Meds: ▫ Paracetamol 250/5, 5mL q4hrs PRN ▫ Famotidine 15mg IV q12hrs
  27. 27. 1st Hospital Day 4TH Day of Illness • S – fever, no epistaxis, no gum bleeding, no vomiting • O - BP: 100/60 HR:86 RR:24 T:39.6 U/O: 3.7cc/kg/hr Skin: flushed, warm with good turgor HEENT: no epistaxis, dry lips Abd: mild epigastric area tenderness Ext: warm, strong pulses, CRT<2 sec
  28. 28. • A – DHF Stage 1, Grade 2 • P – to continue CBC monitoring ▫ To monitor for any sign of bleeding ▫ Identify 1 standby donor for possible plt apheresis ▫ IVF increased to 5cc/kg (80 cc/hr) ▫ Continue meds
  29. 29. DAY 4 OF ILLNESS 5/24/09 12mn 5/24/09 6AM WBC 1.88 1.34 HGB 11.3 11.7 HCT 34.4 35.9 PLT 115 80
  30. 30. 2nd Hospital Day Day 5 of illness • S – fever, (-)BM for 3days, no bleeding, • O - BP: 80/50  90/60 HR:120 RR:25 T:38.6 U/O: 5cc/kg/hr Skin: cold clammy skin HEENT: Pink palpebral conjunctivae, anicteric sclerae, no epistaxis, dry lips, moist tongue
  31. 31. • Abd: flat, normoactive bowel sounds, soft, with mild epigastric tenderness • Ext: cold, strong pulses, CRT 2-3 sec • A – DHF Stage 1, Grade 3 • P – to continue CBC monitoring ▫ Identify 1 standby donor for possible plt apheresis ▫ Continue Paracetamol PRN and Famotidine, Fibrosine 1 sachet ▫ Cefuroxime 500 mg IV q8 (AD:100)
  32. 32. DAY 5 of ILLNESS 5/25/09 5/25/09 1am 6AM WBC 1.06 1.05 Hct 33.3 29.7 Plt 65,000 75,000
  33. 33. 3rd – 4th Hospital Day Day 6 Illness • S – fever, (+)BM, no bleeding • O - BP: 90/60mmHg HR:100-104 bpm RR:25-26 cpm T:38.2-39.2 oC U/O: 5cc/kg/hr Skin: (+) Herman’s rash, warm with good turgor Abd: flat, normoactive bowel sounds, soft, with mild epigastric & RUQ tenderness
  34. 34. • A – DHF Stage 1, Grade 3 • P – to continue CBC monitoring ▫ Identify 1 standby donor for possible plt apheresis ▫ Cefuroxime 500 mg IV q8 (AD:100) ▫ Continue Paracetamol PRN and Famotidine ▫ Cetirizine PO
  35. 35. 3rd and 4th Hospital Day Days 6 and 7 of Illness 5/26/09 5/27/09 12mn 5am 12nn 7pm 6am 12nn 8pm WBC 1.54 1.53 1.66 1.87 2.62 2.72 3.57 Hct 32.8 32.4 32.6 35 34.7 30.8 34.3 Plt 85 60 50 60 85 50 70
  36. 36. 5th Hospital Day Day 8 of Illness, Day 1 afebrile • S – afebrile, no bleeding, with improving appetite • O - BP:90/60 HR:115 RR:26 T:37.6 U/O: 5.2cc/kg/hr Skin: (+) Herman’s rash, warm with good turgor Abd: flat, normoactive bowel sounds, soft, no tenderness Ext: warm, strong pulses, CRT<2 sec
  37. 37. • A – DHF Stage 2(afebrile), Grade 2 • P – to continue CBC monitoring - IVF decreased to 50cc/hr (3.3cc/kg) ▫ Cefuroxime 500 mg IV q8 (AD:100) ▫ Continue Paracetamol PRN and Famotidine ▫ Cetirizine
  38. 38. 5th Hospital Day Day 8 of Illness, Day 1 afebrile 5/28/09 5am 4pm WBC 3.81 5.33 Hct 34.2 34 Plt 65 60
  39. 39. 6th Hospital Day Day 9 of Illness, Day 2 afebrile • S - Afebrile, with improving appetite, not irritable • O - BP:90/60 HR:100 RR:26 T:36.5 U/O: 5cc/kg/hr Skin: (+) Herman’s rash, warm with good turgor HEENT: red inflamed Lips & strawberry tongue, tonsils not enlarged
  40. 40. • A – DHF Stage 3(convalescent), Grade 3 - R/O Kawasaki Disease • P – referred to Pedia for comanagement - IVF decreased to 30cc/hr (2cc/kg) ▫ Cefuroxime was shifted to Imepenem+Cilostazol ▫ Continue Paracetamol PRN and Famotidine ▫ Cetirizine ▫ CRP negative ▫ ESR: 39 (N:0-10)
  41. 41. 6th Hospital Day Day 9 of Illness, Day 2 afebrile 5am 10am WBC 9.35 7.08 Hct 32.5 29.9 Plt 140 140
  42. 42. 7th Hospital Day Day 10 of Illness, Day 3 afebrile • S - Afebrile, with improving appetite, not irritable • O - BP:90/60 HR:104 RR:26 T:37.2 U/O: 5cc/kg/hr Skin: (+) Herman’s rash, warm with good turgor HEENT: Pink palpebral conjunctivae, anicteric sclerae, no epistaxis, reddish lips & tongue, tonsils not enlarged
  43. 43. • C/L: equal chest expansion, clear breath sounds • CVS: distinct heartsounds, no murmur • Abd: flat, normoactive bowel sounds, soft, no tenderness • Ext: warm, strong pulses, CRT<2 sec
  44. 44. • A – DHF Stage 3(convalescent), Grade 3 • P - MGH
  45. 45. Graphical Summary of Temperature
  46. 46. FINAL DIAGNOSIS: • Dengue Hemorrhagic Fever - Grade 3
  47. 47. Dengue Hemorrhagic Fever
  48. 48. Introduction: • Dengue virus • Is an arbovirus • Transmitted by mosquito (Aedes aegypti) • Composed of single-stranded RNA • Has 4 serotypes (DEN-1, 2, 3, 4)
  49. 49. • Each serotype provides specific lifetime immunity vs. the same serotype • All serotypes can cause severe and fatal disease • Some genetic variants within each serotype appear to be more virulent or have greater epidemic potential
  50. 50. Transmission of Dengue virus by Aedes aegypti
  51. 51. Replication and Transmission of Dengue Virus 1. Virus transmitted to human in mosquito saliva 2. Virus replicates in target organs 3. Virus infects wbc and lymphatic tissues 4. Virus released and circulates in blood 5. Second mosquito ingests virus with blood 6. Virus replicates in mosquito midgut and other organs, infects salivary glands 7. Virus replicates in salivary glands
  52. 52. Aedes aegypti • female mosquito • Identified by the white bands or scale patterns on its legs and thorax • Primarily a daytime feeder • Lives around human habitation • Lays eggs and produces larvae preferentially in artificial containers
  53. 53. Vector Control Methods • involves eliminating/controlling the larval habitats where the mosquito lays eggs and the immature mosquitoes develop • Includes emptying water from containers or covering containers that are being used, clean up campaigns to dispose of containers that are not being used
  54. 54. Dengue Fever • acute febrile illness of 2-7 days duration with 2 or more of the ff: • headache • retro -orbital pain • myalgia/arthralgia • rash • petechiae and positive tourniquet test • leukopenia.
  55. 55. WHO criteria for DHF: • Fever, or recent history of acute fever • Hemorrhagic manifestations • Low platelet count (100,000/mm3 or less) • Objective evidence of plasma leakage
  56. 56. Objective evidence of plasma leakage: >Elevated hematocrit (20% over baseline, or 20% drop after volume replacement) >Low protein >Pleural effusion/ ascites • Plasma leakage is the critical difference between DHF and DF
  57. 57. Dengue Shock Syndrome • 4 criteria for DHF • Evidence of circulatory failure manifested by: ▫ Rapid and weak pulse ▫ Narrow pulse pressure/ hypotension ▫ Cold, clammy skin and altered mental status • Frank shock is direct evidence of circulatory failure
  58. 58. Warning Signs for Dengue Shock
  59. 59. Disease Course • Febrile phase lasting 2 -7 days • Critical phase which is about 2-3 days after febrile stage >the patient is afebrile >is at risk of developing DHF/DSS • Convalescent phase – recovery phase >7-10 days after critical stage >Further improvement in general condition and return of appetite >Confluent petechial rash with white center/ itching
  60. 60. Positive Tourniquet Test (+)Torniquet Test: more than 20 petechiae/ sq inch.
  61. 61. Treatment of Dengue Fever • Rest • Fluids. Patients should be encouraged to take small, frequent sips of fluids. If the patient cannot be rehydrated by mouth, fluids should be administered intravenously. At times large amounts of intravenous fluids are needed • Antipyretics—aspirin and NSAIDS such as ibuprofen should be avoided. • Monitoring of BP, urine output, HCT, PLT, and level of consciousness.
  62. 62. Volume Replacement Flow Chart for Patients with DHF Grades I and II
  63. 63. Indications for Hospital Discharge • Absence of fever for 24 hours & return of appetite • Visible improvement in clinical picture • Stable hematocrit • 3 days after recovery from shock • Platelets >50,000/mm³ • No respiratory distress from pleural effusions/ascites Source: Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines . for Prevention and Control. PAHO: Washington, D.C., 1994: 69
  64. 64. Family Assessment Tools
  65. 65. FAMILY CIRCLE Magdalena
  66. 66. Curaraton – Tundag Genogram
  67. 67. FAMILY IN FUNCTIONAL EQUILIBRIUM  Robert John recovered from his illness Ruben was able to go back to work Magdalena can now attend to Mary eve’s needs ADAPTATION •Ruben was able to get a cash advance from his employer STRESSFUL EVENT: •Some of the consultants When Robert John was confined did not charge them at PSH due to fever and was •They were able to diagnosed to have DHF borrow money from Ruben’s siblings FAMILY IN DISEQUILIBRIUM • Ruben misses work • Ruben’s salary deducted •Magdalena couldn’t attend to RESOURCES Mary eve’s needs. •Financial support from Ruben’s siblings. •Neighbors were also helping them by watching over Robert John in the hospital and taking care of Mary eve
  68. 68. FAMILY APGAR Magdalena Curaraton: Mother Almost always Some of the Hardly Ever (2) Time (1) (0) ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me. PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me. GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love RESOLVE: I am satisfied with the way my family and I share time together APGAR SCORE 7: MODERATELY DYSFUNCTIONAL FAMILY
  69. 69. SCREEM Resource Social adequate Robert John’s family participates in social activities such as family reunions, fiesta celebrations of their relatives residing in the provinces. They also have good relationships with their neighbors, friends and co-workers. Cultural adequate They have embraced Filipino values and apply these in their everyday life (i.e. showing respect by kissing the hands of elderly). Religious adequate The family attends mass every Sunday in Capitol Parish and Basilica del Santo Nino. They are aware of religious events in the local community. Economic inadequate Ruben is working as shipper/delivery man of marine products for export and Magdalena is a housewife. Their monthly income is sometimes not enough to provide the basic necessities of the family. Educational adequate Ruben and Magdalena are highschool graduates hence, making them capable of solving problems rationally. Medical adequate When medical problems arise, the family can easily access their private physician to seek consultation for proper medications.
  70. 70. RECOMMENDATIONS To the parents: • Should be educated regarding the proper prevention of dengue. • Should be educated on the signs and symptoms of dengue. • They should have a regular check up of the patient’s well-being and immunizations.
  71. 71. RECOMMENDATIONS Magdalena - mother • Should be educated regarding the proper prevention of dengue. • Make sure that her children get adequate nutrition to increase resistance from any diseases. Ruben – father • Should be compliant of his maintenance medications for psoriasis to prevent flares and avoid missing work. • Should also be educated as well regarding the proper prevention of dengue.
  72. 72. RECOMMENDATIONS To the resident-in charge: • Follow-up with Robert John’s progress and Ruben’s maintenance medications. • Make sure that the family maintains the cleanliness of the surroundings to prevent sources of infection. • To educate the parents of Robert John and their neighbors about the importance of cleanliness in the environment.
  73. 73. RECOMMENDATIONS To the family as a whole if there is suspicion of another possible dengue infection: • Rest, drink plenty of fluids and consult a physician • Avoid pain relievers that contain aspirin and NSAID such as ibuprofen. Paracetamol may be used. • To eliminate mosquito breeding sites and reduce the risk of dengue by checking around their house and to empty buckets, cans, flower pots and other items that may contain water. • Use insect repellents and spray insecticides if there are mosquitoes in the vicinity.
  74. 74. RECOMMENDATIONS ▫ To eliminate any containers where mosquito can lay egg by covering them/turning them upside down ▫ By installing window and door screens
  75. 75. FAMILY DIAGNOSIS • Curaraton-Tundag Family • Nuclear type • Middle class • Father – breadwinner • Mother – primary caregiver • The stage of family cycle: Family with Young Children • APGAR Assessment: Moderately Dysfunctional Family (Score 7) • Smilkstein’s Family Cycle: family is in equilibrium. • Evaluation by SCREEM showed resource and strength of Social, Cultural, Religion, Education, and Medical factors and weakness and pathology in economic factor.

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