In this presentation we present a case of a 20 year old male who came in due to fever.

1. Comes with
the Tide
Zennia Patrice A. Cabrieto
First Year

2. 1. To discuss the case of a 20 year old, male patient
who presented with fever.
2. To discuss the diagnostic approach and
management based on the guidelines
3. To discuss the complications and updates on the
disease.
Objectives

3. General Data
J.E.K.
20/M
Fever

4. 4
Days
PTA
• intermittent febrile episodes (Tmax =
40°C)
• throbbing headache at occipital area 5/10
• sought consult
• Cefuroxime 500mg tab BID
• Paracetamol 500mgtab q4h
• Vitamin C tab OD
History of Present Illness

5. 3
Days
PTA
• maculopapular rashes and petechiae
• post Prandial Vomiting
• loose stools, non-mucoid, non-bloody
• sought consult with another AP
• Laboratories: CBC platelet count,
Urinalysis, Dengue NS1 IgG and IgM
• Cefixime 400mg capsule OD
History of Present Illness

6. History of Present Illness
Complete Blood Count
Normal Values 6/09/21
Hgb 14-17.5 15.5
Hct 41.5 – 50.4 46
WBC 4.5 - 11 2.8
Stabs 50 - 70
Segmenters 20 - 45 79
Lymphocytes 0 - 8 20
Monocytes 0-2 1
Platelet 150 - 450 210
Urinalysis
Sugar Neg
Albumin Neg
RBC 0-1
WBC 0-1

7. On the
Day of
Admissio
n
History of Present Illness
• Repeat labs requested:
• CBC platelet
• APTT
• Protime
• Persistence of signs and symptoms

8. History of Present Illness
Complete Blood Count
N.V. 6/09/21 6/11/21 6/13/21
Hgb 14-17.5 15.5 15.5 17.1
Hct 41.5 – 50.4 46 46 50.7
WBC 4.5 - 11 2.8 2.8 4.4
Stabs 50 - 70 79 71
Segment
ers
20 - 45
79 20 25
Lymphoc
ytes
0 - 8
20 1 4
Monocyt
es
0-2
1 210
Platelet 150 - 450
210
A 24
71
APTT Protime
46.6 secs
13.4 secs
98%
INR 1.01

9. History of Present Illness
• Repeat labs requested:
• CBC platelet
• APTT
• Protime
• Persistence of signs and symptoms
Patient opted for admission as advised
On the
Day of
Admissio
n

10. Past
Medical
No known comorbidities
No previous hospitalizations
No known food and drug
allergies
Family
Hypertension
(Paternal Side)
Personal/Soci
al
College student graduate
Occasional smoker and
alcoholic beverage drinker

11. Physical
Examination

12. Awake, ambulatory
Not in cardiopulmonary distress
Afebrile (36.0°C)
BP 90/70mmHg
CR 86bpm
RR 20cpm
O2 saturation at RA 98%
Obese Class I
(BMI 30.1 Ht 152cm Wt 69.5kg)
General Survey

13. anicteric sclerae, pinkish conjunctiva, dry lips, dry tongue
symmetrical chest expansion, clear breath sounds,
multiple maculopapular rashes
adynamic precordium, regular cardiac rate and rhythm
soft nontender abdomen, multiple maculopapular rashes
multiple maculopapular rashes, no peripheral edema
unremarkable neurologic examination
Other Findings

14. Dengue Fever with
Warning Signs

15. At the ER
4th Day of Illness
Diet: DAT, no dark colored foods
IVF: PNSS 1L x 150cc/hr
Fast drip 500cc
O2 at 2lpm
Labs:
• CBC platelet
• Na K SGPT
• CXR – PA
• APTT, Protime
• Fecalysis
Medications:
• Omeprazole 40mg IV now, then
40mg/tab 1 tab OD
• Metoclopramide 1 amp IV now
then Q8H PRN
• Domperidone 10mg/tab 1 tab
TID
• Vitamin C + Zinc 1 capsule OD
• Paracetamol 500mg/tab Q4H
PRN for Temp >37.5C or
headache
• Chlorhexidine oral care

16. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
Hgb 14-17.5 15.5 17.1 16.9
Hct 41.5 – 50.4 46 50.7 50.3
WBC 4.5 - 11 2.8 4.4 4.3
Neutro 50 - 70 79 71 Stab 3
Seg 57
Lymphocytes 20 - 45 20 25 36
Monocytes 0 - 8 1 4 4
Platelet 150 - 450 210 A 24
M 71
A 18
M 58
Blood Chemistry
N. V. 6/13/21
Sodium 136 - 145 134
Potassium 3.5 – 5.1 4
SGPT 16 - 63 252

17. At the Wards
5th Day of Illness
Vital signs:
BP: 110/80mmHg
Temp: 36.3°C
PR: 72bpm
RR: 20bpm
O2 sat: 98%
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Regular cardiac rhythm
Multiple maculopapular rashes on
arms and back
IVF: PNSS1L x 150cc/hr
Replace GI losses volume per volume
Dengue Fever with Warning Signs

18. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
Hgb 14-17.5 15.5 17.1 16.9 17.5
Hct 41.5 –
50.4
46 50.7 50.3 51.5
WBC 4.5 - 11 2.8 4.4 4.3 4.2
Neutro 50 - 70 79 71 Stab 3
Seg 57
Stab 1
Seg 44
Lymphocyt
es
20 - 45 20 25 36 48
Monocytes 0 - 8 1 4 4 7
Platelet 150 - 450 210 A 24
M 71
A 18
M 58
A 66
M 156
Fecalysis
no intestinal parasites seen

19. At the Wards
6th Day of Illness
Vital signs:
BP: 110/80mmHg
Temp: 36.3°C
PR: 72bpm
RR: 20bpm
O2 sat: 98%
(+) 2 eps of loose watery stools
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Regular cardiac rhythm
Multiple maculopapular rashes on
arms and back
Medications continued
Replace GI losses volume per volume
Dengue Fever with Warning Signs

20. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
6/14/21
4am
6/14/21
10am
6/14/21
4pm
6/14/21
10pm
Hgb 14-17.5 15.5 17.1 16.9 17.5 15.8 16.5 17.5 16.7
Hct 41.5 –
50.4
46 50.7 50.3 51.5 46.1 48.1 51.2 49
WBC 4.5 - 11 2.8 4.4 4.3 4.2 4.7 5.2 4.9 5.2
Neutro 50 - 70 79 71 Stab 3
Seg 57
Stab 1
Seg 44
Seg 74 Stab 1
Seg 42
Stab 2
Seg 24
Stab 1
Seg 35
Eo 2
Lymphocytes 20 - 45 20 25 36 48 74 56 74 59
Monocytes 0 - 8 1 4 4 7 1 2
Platelet 150 - 450 210 A 24
M 71
A 18
M 58
A 66
M 156
A 13
M 69
A 15
M 42
A 19
M 45
A 12
M 31

21. At the Wards
7th Day of Illness/Day 3 Afebrile
Vital signs:
BP:90- 120/60-80mmHg
Temp: 36.3°C – 36.7°C
PR: 72 – 81 bpm
RR: 20bpm
O2 sat: 98%
Abdominal discomfort
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Multiple maculopapular rashes on
arms and back
Hydration continued
Serial CBC determination
Dengue Fever with Warning Signs

22. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
6/14/21
4am
6/14/21
10am
6/14/21
4pm
6/14/21
10pm
6/15/21
4am
6/15/21
4pm
Hgb 14-17.5 15.5 17.1 16.9 17.5 15.8 16.5 17.5 16.7 15.5 15.3
Hct 41.5 –
50.4
46 50.7 50.3 51.5 46.1 48.1 51.2 49 45.3 44.6
WBC 4.5 - 11 2.8 4.4 4.3 4.2 4.7 5.2 4.9 5.2 6.3 5
Neutro 50 - 70 79 71 Stab 3
Seg 57
Stab 1
Seg 44
Seg 74 Stab 1
Seg 42
Stab 2
Seg 24
Stab 1
Seg 35
Eo 2
Stab 1
Seg 47
Seg 32
Eo 1
Lymphocytes 20 - 45 20 25 36 48 74 56 74 59 49 67
Monocytes 0 - 8 1 4 4 7 1 2 3
Platelet 150 - 450 210 A 24
M 71
A 18
M 58
A 66
M 156
A 13
M 69
A 15
M 42
A 19
M 45
A 12
M 31
A 20
M 43
A 28
M 66

23. At the Wards
8th Day of Illness/Day 4 Afebrile
Vital signs:
BP:100- 120/60-80mmHg
Temp: 36.1°C – 36.9°C
PR: 75 – 81 bpm
RR: 20bpm
O2 sat: 98%
Decreasing bdominal discomfort
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Multiple maculopapular rashes on
arms and back
IVF decreased to 100cc/hr
Serial CBC determination
Dengue Fever with Warning Signs

24. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
6/14/21
4am
6/14/21
10am
6/14/21
4pm
6/14/21
10pm
6/15/21
4am
6/15/21
4pm
6/16/21
Hgb 14-17.5 15.5 17.1 16.9 17.5 15.8 16.5 17.5 16.7 15.5 15.3 15.5
Hct 41.5 – 50.4 46 50.7 50.3 51.5 46.1 48.1 51.2 49 45.3 44.6 44.5
WBC 4.5 - 11 2.8 4.4 4.3 4.2 4.7 5.2 4.9 5.2 6.3 5 5.2
Neutro 50 - 70 79 71 Stab 3
Seg 57
Stab 1
Seg 44
Seg 74 Stab 1
Seg 42
Stab 2
Seg 24
Stab 1
Seg 35
Eo 2
Stab 1
Seg 47
Seg 32
Eo 1
Stab 1
Seg 30
Eo 1
Lymph 20 - 45 20 25 36 48 74 56 74 59 49 67 63
Mono 0 - 8 1 4 4 7 1 2 3 4
Platele
t
150 - 450 210 A 24
M 71
A 18
M 58
A 66
M 156
A 13
M 69
A 15
M 42
A 19
M 45
A 12
M 31
A 20
M 43
A 28
M 66
A 48
M 137

25. At the Wards
9th Day of Illness/Day 5 Afebrile
Vital signs:
BP:100- 120/60-80mmHg
Temp: 36.1°C – 36.9°C
PR: 75 – 81 bpm
RR: 20bpm
O2 sat: 98%
Decreasing bdominal discomfort
Decreasing pruritus
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Flushing of the arms and legs
Dengue Fever with Warning Signs

26. Results
Complete Blood Count
N.V. 6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
6/14/21
4am
6/14/21
10am
6/14/21
4pm
6/14/21
10pm
6/15/21
4am
6/15/21
4pm
6/16/21 6/17/21
4am
Hgb 14-17.5 15.5 17.1 16.9 17.5 15.8 16.5 17.5 16.7 15.5 15.3 15.5 14.6
Hct 41.5 –
50.4
46 50.7 50.3 51.5 46.1 48.1 51.2 49 45.3 44.6 44.5 43
WBC 4.5 - 11 2.8 4.4 4.3 4.2 4.7 5.2 4.9 5.2 6.3 5 5.2 5.9
Neutr
o
50 - 70 79 71 Stab 3
Seg 57
Stab 1
Seg 44
Seg 74 Stab 1
Seg 42
Stab 2
Seg 24
Stab 1
Seg 35
Eo 2
Stab 1
Seg 47
Seg 32
Eo 1
Stab 1
Seg 30
Eo 1
Stab 1
Seg 36
Lymp
h
20 - 45 20 25 36 48 74 56 74 59 49 67 63 63
Mono 0 - 8 1 4 4 7 1 2 3 4
Platel
et
150 - 450 210 A 24
M 71
A 18
M 58
A 66
M 156
A 13
M 69
A 15
M 42
A 19
M 45
A 12
M 31
A 20
M 43
A 28
M 66
A 48
M 137
A107
M 252

27. At the Wards
10th Day of Illness/Day 6 Afebrile
Vital signs:
BP:100- 120/60-80mmHg
Temp: 36.5°C
PR: 82 bpm
RR: 20bpm
O2 sat: 98%
Decreasing abdominal discomfort
No pruritus
Awake, conversant
Dry lips, moist tongue
Clear breath sounds
Flushing of the arms and legs
Dengue Fever with Warning Signs

28. Results
Complete Blood Count
6/11/21 6/13/21
10am
6/13/21
4pm
6/13/21
10pm
6/14/21
4am
6/14/21
10am
6/14/21
4pm
6/14/21
10pm
6/15/21
4am
6/15/21
4pm
6/16/21 6/17/21
4am
6/18/21
4am
Hgb 15.5 17.1 16.9 17.5 15.8 16.5 17.5 16.7 15.5 15.3 15.5 14.6 15
Hct 46 50.7 50.3 51.5 46.1 48.1 51.2 49 45.3 44.6 44.5 43 44.2
WBC 2.8 4.4 4.3 4.2 4.7 5.2 4.9 5.2 6.3 5 5.2 5.9 6.3
Neutr
o
79 71 Stab 3
Seg 57
Stab 1
Seg 44
Seg 74 Stab 1
Seg 42
Stab 2
Seg 24
Stab 1
Seg 35
Eo 2
Stab 1
Seg 47
Seg 32
Eo 1
Stab 1
Seg 30
Eo 1
Stab 1
Seg 36 Seg 24
Eo 3
Lymp
h
20 25 36 48 74 56 74 59 49 67 63 63 68
Mono 1 4 4 7 1 2 3 4 5
Platel
et
210 A 24
M 71
A 18
M 58
A 66
M 156
A 13
M 69
A 15
M 42
A 19
M 45
A 12
M 31
A 20
M 43
A 28
M 66
A 48
M 137
A107
M 252
214