1. PICU AUDIT

2. Objectives • To present a new approach of management of dengue fever

3. General Data • LN • 2 year old • Female • 15.2 kg • February 27, 2012 • Malaysian • Hindhu • Lives in Malaysia • Admitted last May 16, 2014

4. Chief Complaint • Fever

5. History of Present Illness 11 days PTA • Undocumented fever • Paracetamol • 1 day • No other symptoms • No consult done

6. History of Present Illness 10 days PTA • Fever resolved • Good appetite • Good activity

7. History of Present Illness 7 days PTA • Fever Tmax 39 • Consult in Malaysia • Serial CBCPC

8. Laboratories

9. Laboratories

10. History of Present Illness 4 days PTA • Patient discharged • A> Viral Infection • Given Azithromycin

11. History of Present Illness 3 days PTA • Afebrile • Playful • Active

12. History of Present Illness Morningof admission • Febrile • Paracetamol • Poor oral intake • Decreased activity • Weak looking • Vomiting episodes • Consult TMC ER ADMITTED

13. Past Medical History • No asthma, allergies • No previous surgeries nor hospitalizations

14. Family History • Hypertension • DM

15. Birth History • Full term via NSD to a 42 year old G1P1 (1001)

16. Immunizations • Complete for age • With booster doses

17. Feeding History • Eats a regular diet • No food allergies

18. Review of Systems • General:Noweight loss,poor appetite • Skin:Flushed, no rashes • Head: No migraines, dizziness and head injuries • Eyes: No blurring of vision • Ears: Good hearing, no tinnitus, earaches, infection, vertigo, no discharges • Nose: No nasal stuffiness, discharge, and itching, nosebleeds, and sinus trouble • Throat (Mouth/Pharynx): No sore tongue, dry mouth, sore throat, hoarseness, and ache in the teeth and gums • Neck: No lumps, swollen glands, goiter, pain/stiffness of neck

19. Review of Systems • Cardiovascular: No palpitations, orthopnea, easy fatigability • Respiratory:Nocough, sputum, hemoptysis • Gastrointestinal: No diarrhea, constipation, nausea,(+) vomiting, no abdominal pain • Genital:No genital infections, lesions. • Renal: No polyuria, dysuria, normal urine color • Neurologic: No fainting spells, seizures, paralysis, numbness, and tremors • Psychiatric:No anxiety, tension, depression, and memory change. He has never had suicidal attempts.

20. Physical Examination (ER) • General Survey: Awake,ambulatory, not in cardiorespiratory distress • Vital Signs: BP 90/60 HR 120 RR 25 T 38.6 Height: 93 cm Weight: 15.2 kg BMI 17.6 IBW 12 kg Pain scale 0/10

21. Physical Examination • Skin: Flushed, good turgor • HEENT: Normocephalic, pink palpebral conjunctiva, anicteric sclerae, nasal septum midline, hyperemic posterior pharyngeal wall • Neck: Supple neck, Non palpable cervical lymph nodes, thyroid not enlarged

22. Physical Examination • Respiratory: Symmetrical chest expansion, no retractions, clearbreath sounds • Cardiac: Adynamic precordium, normal rate, regular rhythm, no murmur • Abdomen: Normoactive bowel sounds, Soft, non tender, no hepatomegaly • Extremities: No cyanosis, swelling, full and equal pulses

23. Neurologic Examination • Mental Status:GCS 15, conversant, active, irritable • Cranial Nerves: • Cranial nerves: I – not assessed II – pupils 2-3mm ERTL III, IV, VI – extraocular muscles intact V – intact corneal reflex V1, V2, V3 intact VII – no facial asymmetry VIII – intact gross hearing IX, X – good gag reflex XI – can shrug shoulders XII – tongue midline

24. Neurologic Examination • Motor: 5/5 • Cerebellar: No dysmmetria, dysdiadokinesia • Sensory: No sensory deficit • Reflex: +2 on all extremities • No babinski, meningeal signs

25. INITIAL IMPRESSION Systemic viral illness

26. Admitting Orders Diagnostics Therapeutics IVF: D5NM at Maintainance + 10 or 3.8 ml/kg Paracetamol at 13 mkdoseq4 for T≥37.8 • CBC • Urinalysis

27. Laboratories

28. 1st hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 2 of illness No complaints Poor oral intake Urine output 1 ml/kg in 8 hours BP 100/60 HR 126 RR 26 T 39.2-40.7 Flushed Slightly hypermeic tonsils Clear breath sounds Regular rhythm Soft abdomen, nontender Full pulses, warm extremities, CRT >2sec SVI r/o Dengue fever • Repeat CBC • Dengue Ns1 • Dengue blot • Dengue PCR • BCS

29. Laboratories Dengue Ns1: positive Dengue blot: negative Dengue PCR: Type 1

30. 1st hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 1 of Illness No complaints Poor oral intake Urine output 1.4ml/kg BP 100/60 HR 126 RR 26 T 38-40.7 Flushed Slightly hypermeic tonsils Clear breath sounds Regular rhythm Soft abdomen, nontender Full pulses, warm extremities, CRT>2sec Dengue fever • IVF increased 3.8 ml/kg • Daily cbc monitoring

31. 2nd hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 2 of Illness Loose stools + particles x 1 Urine output 2 ml/kg BP 90/60 HR 112 RR 24 T 38.4-39.6 Flushed Puffy eyelids, bilateral Dry lips Clear breath sounds Regular rhythm Soft abdomen, nontender Full pulses, warm extremities, CRT >2sec Dengue fever • Decreased IVF to 3 ml/kg • Daily cbc monitoring

32. Laboratories

33. 3rd hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 3 of Illness Loose stools x 2 Still with puffy eyes Urine output 1.3 ml/kg BP 90/60 HR 118 RR 26 T 38.1-40.2 Flushed Decreased eye puffiness Clear breath sounds Regular rhythm Soft abdomen, nontender Full pulses, warm extremities, CRT >2sec Dengue fever • Decreased IVF to 2.7ml/kg • Probiotics • Daily cbc monitoring

34. Laboratories

35. 4th hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 4 of Illness Occasional cough Abdominal pain No recurrence of loos stools Urine ouput 1.7 ml/kg BP 100/60 HR 110 RR 28 T 37.5-39.1 Flushed Maculopapular rashes on face Oral sores Clear breath sounds Regular rhythm Soft abdomen, nontender Full pulses Dengue fever • Fluid is maintained • Daily cbc monitoring

36. Laboratories

37. 5th hospital stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 5 of Illness Persistence of abdominal pain Urine ouput 2.9 ml/kg BP 100/60 HR 110 RR 28 T 37.3-38.7 Flushed Maculopapular rashes on face Puffy eyes Oral sores Clear breath sounds Regular rhythm Abdominal distention Full pulses Nonpitting bipedal edema Dengue fever with warning signs • Cardiac, liver enzymes • Kidney function • Bleeding parameters • Electrolytes • Albumin • Gastro referral • Cardiac referral

38. Laboratories

39. Laboratories

40. Gastro • A> Dengue Hepatitis

41. Cardio

42. Cardio • 2d echo • Small pericardial effusion, pleural effusion, normal intracardiac structure • A> Dengue Myocarditis

43. 5th hospital stay (2 hrs prior to transfer) SUBJECTIVE OBJECTIVE ASSESSMENT PLAN DOB BP 90/60 HR 120 RR 41 T 36 Decreased breath sounds on right base Dengue fever with warning signs Dengue Hepatitis Dengue Myocarditis • Transfer to PICU • HGT 91 • Chest xray

44. AT PICU SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 5 of Illness No abdominal pain No recurrence of loose stools Urine output 2.7 ml/kg BP 105/52 HR 112 RR 69 T 36.9 Flushed decreased breath sounds right base Regular rhythm Soft, nontender abdomen, no hepatomegaly Full pulses, CRT < 2 sec, warm extremities Dengue fever with warning signs Dengue Hepatitis Dengue Myocarditis • Serial cbc monitoring

45. Laboratories

46. WBC vs Platelet

47. Chest Xray • Pleural effusion right • Intercurrent Pneumonia not ruled out

48. AT PICU SUBJECTIVE OBJECTIVE ASSESSMENT PLAN No complaints Albumin 2.0 Hct 31 from 36 (14% decreased) Dengue fever with warning signs Dengue Hepatitis Dengue Myocarditis • pRBC transfusion (5ml/kg) • Albumin infusion (1g/kg)

49. 1st PICU stay SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Day 6 of Illness Going Day 1 afebrile Minimal abdominal pain Better well being Urine output 2.7 ml/kg BP 118/70 HR 125 RR 34 T 37.3 Flushed decreased breath sounds right base Shallow subcostal retractions Regular rhythm Soft, nontender abdomen Full pulses, CRT < 2 sec, warm extremities Dengue fever with warning signs Dengue Hepatitis Dengue Myocarditis • Serial cbc monitoring q6 • Electrolytes • Albumin • Chest xray • Furosemide 0.4mg/kg/dose given 2 doses

50. Laboratories