Pediatric Community Acquired Pneumonia

CASE MANAGEMENT
CONFERENCE
Presented by:
Allan Joseph O. Santos
Nurol Iman L. Cabugatan
Amer Hussien P. Samporna
Department of Pediatrics
November 21, 2014
8:00 – 10:00 am
Basilio Valdes Hall

IDENTIFYING DATA
• M.D.
• 2 yr & 2 mos old
• Female
• Filipino
• Roman Catholic
• Makati City
• 2nd admission
• October 25, 2014 ( 3:19 pm )

CHIEF COMPLAINT
Cough with fever

SOURCE & RELIABILITY
• SOURCE : Mother
• RELIABILITY : Good ( 95% )

HISTORY OF PRESENT ILLNESS
• Fever : intermittent
: high grade
: Tmax : 40o C
• No other symptoms
• Self medicated : Paracetamol (15mkdose)
9 days PTA .

• Consult OLLH-ER : laboratory exam
9 days PTA . .
CBC PC RESULT
Hemoglobin 124
Hematocrit 0.37
WBC
3.9 
Segmenters 0.64
Stabs 0.01
Lymphocytes 0.30
Monocytes 0.05
Platelet count 268
URINALYSIS RESULT
Color Yellow
Transparency Slightly Cloudy
Reaction 6.0
Specific gravity 1.015
Glucose Negative
Albumin Negative
Epithelial cells Few
RBC 2-4/hpf
Pus cells 0-1/hpf
Amorphous urates Few
Mucus threads Occasional
Bacteria Occasional

• Consult OLLH-ER : PE : Normal
: Dx : AVI
: Tx : Paracetamol (15mkdose)
: sent home
• Symptoms : resolved
9 days PTA . . .

• Afebrile
• Cough : occasional
: non productive
• No : other signs and symptoms
: consult
• Self medicated : Salbutamol + Bromhexine + Guaifenesin syrup
: Salbutamol + Ipratropium nebule
• Symptom : temporary relief
7 days PTA

• Cough : persisted
: productive
• Fever : recurrent
: intermittent
: high grade
: Tmax : 39o C
• Other symptoms : body malaise
: poor appetite
• No consult
1 day PTA

• Fever
• Cough
• Poor appetite
• Body malaise
• Consult AMD : PE : weak looking, dry lips
: admission
Few hours PTA

MATERNAL HISTORY
• Mother : 27 year old
: G3P2 (2002)
• Pre-natal check up : regular
• Maternal illness : UTI
• Exposure to radiation : none
• Multivitamins : compliant
• Folic Acid : compliant
• Ferrous Sulfate : compliant

BIRTH HISTORY
• Full term, NSD
• Lying-in clinic
• Birth date : August 23, 2012
• BW : 3.5 kg ( 3,500 grams ) ( 7.7 lbs. )
• BL : 50 cm
• NST : normal
• NHT : not done
• Given at Birth : Vit K
: Hepa B

VACCINE 1ST DOSE 2ND DOSE 3RD DOSE
BCG 13 days
(9/5/2012)
Hepatitis B Birth
(8/23/2012)
2 mos & 1 day
(10/24/2012)
3 mos
(11/21/2012)
DPT 2 mos & 1 day
(10/24/2012)
3 mos
(11/21/2012)
4 mos & 12 days
(1/2/2013)
OPV 2 mos & 1 day
(10/24/2012)
3 mos
(11/21/2012)
4 mos & 12 days
(1/2/2013)
Hib 2 mos & 1 day
(10/24/2012)
3 mos
(11/21/2012)
4 mos & 12 days
(1/2/2013)
Measles 9 mos & 17 days
(6/9/2013)
MMR 1 yr & 1 mo
(9/18/13)
IMMUNIZATION HISTORY
Patient’s immunization Record

Childhood Immunization Schedule 2014

NUTRITIONAL HISTORY
• Breast fed : Birth until 6 mos
• Milk formula : 6 mos onwards
• Solid : 6 mos onwards
• Current diet : 8oz of milk TID
: rice, meat, fruits
• Multivitamins : Regular

DEVELOPMENTAL HISTORY
GROSS MOTOR ADAPTIVE FINE
MOTOR
LANGUAGE PERSONAL/SOCIAL
• Runs well
• Up, down, stairs
alone
• Imitates circular
strokes
• Draw shapes
• Combine two or
three words in
sentence
• Point to one
body part
• Removes
garment
• Toilet trained

ADMISSION HOSPITAL DATE AGE DIAGNOSIS
1 OLLH Feb 2013 6 months old AGE
PAST MEDICAL HISTORY
OPD CLINIC DATE AGE DIAGNOSIS
1 Other AMD Nov 2013 1 yr & 3 mos PCAP A
2 AMD Jan 2014 1 yr & 5 mos PCAP A
3 AMD Feb 2014 1 yr & 8 mos PCAP A

( + ) : Asthma (Mother)
: Hypertension (Maternal grand parent)
: CVA (Maternal Grandfather)
( - ) : Mental/Psychiatric disorder
: Tuberculosis
: Diabetes mellitus
: Malignancy
: Thyroid disease
FAMILY MEDICAL HISTORY

• Youngest among three siblings
• Father : 60 year old
: Government employee
• Mother : 30 year old
: Call center agent
PERSONAL & SOCIAL HISTORY

• Home : 2-storey rented house
( with 2 siblings and 1 helper )
• Water : Refilling station
• Garbage : Collected daily
PERSONAL & SOCIAL HISTORY

• General: no weight loss
• Skin : no jaundice
: no bruising
• HEENT : no head injury, no trauma
: no ear discharge
: no nasal discharges, no epistaxis
: no mouth sores
: no mass
REVIEW OF SYSTEMS

• Neurologic : no seizure
: no loss of consciousness
• Respiratory : no colds
: no hemoptysis
Cardiovascular : no cyanosis
REVIEW OF SYSTEMS

• Gastrointestinal : no vomiting
: no change in bowel movement
• Musculoskeletal : no swelling
: no arthralgia
: no myalgia
: no limitation of movement
• Genitourinary : no hematuria
: no dysuria
: no polyuria
: no urinary frequency
: no foul smelling vaginal discharge
REVIEW OF SYSTEMS

• GENERAL SURVEY : awake, conscious, weak-looking,
carried by mother
• VITAL SIGNS : BP : 90/60 mmHg
: HR : 115 bpm
: RR : 33 cpm
: Temp : 37.8 o C
: O2 Sat : 98 %
• ANTHROPOMETRICS : Weight : 13.9 kg (z-score +1: normal)
: Height : 89 cm (z-score +1: normal)
: BMI : 17.5 kg/m2 (z-score +1: normal)
: HC : 49 cm
: CC : 51 cm
: AC : 53 cm
PHYSICAL EXAMINATION

• SKIN : warm, fair, no lesion, flushed skin,
good skin turgor
• HEENT : anicteric sclerae, pink palpebral conjunctivae,
no hemorrhage, no exudates, no discharges,
dry lips and oral mucosa, no oral lesions,
no lymphadenopathies
• RESPIRATORY : shallow retractions, symmetrical chest
expansion. rales on all lung fields.
• CARDIOVASCULAR : adynamic precordium, no heaves and
thrills, regular heart rhythm.
distinct heart sounds, no murmurs

• GASTROINTESTINAL : flat, no surgical scars, normoactive
bowel sounds, no bruits, tympanitic
abdomen, no organomegaly,
no tenderness.
• EXTREMETIES : CRT <2 sec., no gross deformity,
no edema, full and equal pulses.
• GENITALIA : labia majora covers labia minora,
no vaginal discharge, no lesions

• NEUROLOGICAL
Cerebral : GCS 15 (E4V5M6)
Cerebellar : Not done
Cranial Nerves
CN I : able to smell
CN II : intact papillary and consensual light
reflexes (+) ROR
CN III, IV, VI : full EOMs
CN V : intact; no sensory deficits
CN VII : no facial asymmetry; able to perform
different facial expressions
CN VIII : intact gross hearing
CN IX, X : intact gag reflex; uvula midline
CN XI : SCM and trapezius muscle symmetric
with muscle strength of 5/5
CN XII : tongue midline

• NEUROLOGICAL
Motor : 5/5 on both lower and upper extremities
normal tone; no atrophy; symmetrical
movements
Sensory : responsive to light touch and pain
DTRs : ++ on biceps and knee
Meningeal Signs : no kernig’s and brudzinski’s, nuchal
rigidity
Pathologic Reflex : no babinski, clonus

Gen. data : 2yr & 2mos old, female
CC : Cough with fever
HPI : fever (Tmax : 40OC)
: productive cough
: body malaise
: poor appetite
PE : weak-looking,
flushed skin, dry lips and
oral mucosa,
shallow retractions,
rales on all lung field,
tachypnea (33cpm)
febrile (37.8o C)
SALIENT FEATURES

1. Pediatric Community Acquired Pneumonia C
2. Rule out : Dengue Fever (without warning signs)
ADMITTING DIAGNOSIS

1. Pediatric Community Acquired Pneumonia C
2. Rule out : Dengue Fever without warning signs
ADMITTING DIAGNOSIS

Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH
Classification : CAUSE
NON INFECTIOUS Aspiration of food and gastric acid
Foreign bodies
Hypersensitivity reactions
INFECTIOUS Viral
fungal
Bacterial

COUGH
Classification: ANATOMY
UPPER Nasal cavity
Pharynx
Larynx
LOWER Trachea
Bronchus
Bronchioles
Lungs
Upper Respiratory Tract
Lower Respiratory Tract

COUGH
Classification: SIGNS and SYMPTOMS
UPPER Cough
Sore throat
Rhinorrhea
Nasal congestion
Headache
Low grade fever
Facial pressure
Sneezing
LOWER Cough
Fever
Chest pain
Tachypnea
Sputum production
Retractions
Upper Respiratory Tract
Lower Respiratory Tract

COUGH
Classification: Etiology
UPPER Virus
• Adenovirus
• Influenza
• Parainfluenza
• Respiratory syncytial
• Rhinovirus
Bacteria
• H. influenzae
• S. pyogenes
Fungi
• Candida spp.
LOWER Virus
• Adenovirus
• Influenza
• Parainfluenza
• Respiratory syncytial
• Rhinovirus
Bacteria
• H. influenzae
• S. pyogenes
• B. pertusiss
• S. pneumonia
• S. aureus
Other
• M. Pneumoniae
• C. pneumoniae

COUGH
Classification: AGE
< 2 years Bronchiolitis
Pneumonia
Croup
> 2 years Croup
Pharyngitis
Pulmonary Tuberculosis
Pneumonia

COUGH
Classification Upper Respiratory Infection Lower Respiratory Infection
Anatomy Nasal cavity
Pharynx
Larynx
Trachea
Bronchus
Bronchioles
Lungs
Etiologic agents Respiratory syncytial virus
Adenovirus
H. infuenzae
Parainfluenzae
Rhinoviruses
S. pyogenes
S. pneumoniae
Respiratory syncytial virus
Adenovirus
H. infuenzae
Parainfluenzae
S. pneumoniae
M. pneumoniae
S. aureus
M. tuberculosis
Signs & symptoms Cough
Sore throat
Rhinorrhea
Nasal congestion
Headache
Low grade fever
Facial pressure
Sneezing
Cough
Fever
Chestpain
Tachypnea
Sputum production
Retractions
Differential
Diagnosis
Tonsillitis
Pharyngitis
Laryngitis
Sinusitis
Rhinitis
Bronchitis
Pulmonary Tuberculosis
Pneumonia

PNEUMONIA
Definition
• Leading cause of death in children world wide
• Lung parenchymal inflammation
Nelson Textbook of Pediatrics 19 th ed. 2011

PNEUMONIA
WHO : Common diseases of children under 5 y/o
Nelson Textbook of Pediatrics 19 th ed. 2011

Revised Risk Classification for
Pneumonia-related Mortality
Philippine Academy of Pediatric Pulmonologists 2012

INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS
World Health Organization 2005

PNEUMONIA
SOURCES
Pediatrics
by Nelson
Fundamentals of
Pediatrics
by Navarro
Pediatrics Infectious
Disease
By feign & cherry
Definition Inflammation of the
parenchyma of the lungs
Most common cause of
morbidity and mortality
Is an acute lung infection that
results most commonly from
viral or bacterial pathogens
Signs & Symptoms Fever
Cough
IC/SC Retraction
Cyanosis
Tachypnea
Rales/crackles
Nasal flaring
Respiratory fatigue
Fever
Chills
Cough
Retraction
Tachypnea
Restlessness
Irritability
Poor feeding
Chest indrawing
Chest pain
Hypoxemia
Tachypnea
Grunting
Fever
Cough
Retraction
Body Malaise
Tachycardia
Dyspnea
Altered mental status
Rales
Diagnostics Chest X-ray
CBC
Blood culture
Chest x-ray
ABG
CBC
Blood culture
Pulse oximetry
Chest X-ray
CBC

DENGUE FEVER
Definition
• Is an acute febrile illness
• Arthropod-borne virus
• Characterized
: biphasic fever
: myalgia
: rash
: leukopenia
: lymphadenopathy

DENGUE FEVER
Epidemiology
• Southeast Asia and Western Pacific Region
– World wide : 1.8 billion
– >70 % of the population who are at risk of dengue.
• PHILIPPINES : 2013 (127,861)
: 2014 (49,591) Jan – Aug
Department of health Philippines

DENGUE FEVER
Aedes Aegypti
• Daytime-biting mosquito
• highly domesticated
• breeds in water stores
– Drinking
– Washing
– container collecting fresh water

DENGUE FEVER
DENGUE FEVER DENGUE HEMORRHAGIC FEVER
Clinical Manifestation :
• Fever
• Pharyngeal inflammation
• Rhinitis
• Cough
• Body malaise
• anorexia
Clinical Manifestation :
• Cold clammy extremities
• Warm trunk
• Flushed face
• Restlessness
• Irritability
• Mild epigastric pain and decrease urinary output
Nelson’s textbook of pediatrics 19th edition

DENGUE FEVER
OLD
(Revised 1997/2011 Case Definition of Dengue & Levels of Severity)
NEW
(Revised DOH/PPS Classification and Levels of severity 2011)
Case definition for Dengue Fever
Probable Dengue:
An acute febrile illness with 2 or more of the following:
• Headache
• Retro-orbital pain
• Arthralgia
• Rash
• Hemorrhagic manifestations
• Leukopenia;
AND
• Supportive serology (a reciprocal HI antibody titers ≥1280, a
comparable IgG assay ELISA titer or IgM antibody test on a late or
acute convalescent phase serum specimen
Confirmed:
A case confirmed by laboratory criteria
Case definition for Dengue with out warning signs
Probable Dengue:
Lives in or travel to dengue-endemic area, with fever, plus two of
the following:
• Headache
• Body malaise
• Myalgia
• Arthralgia
• Retro-orbital pain
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Flushed skin
• Rash (petechial, hermann’s rash)
• Tourniquet test (+)
AND
• Laboratory test, at least CBC (leukopenia with or without
thrombocytopenia) and/or dengue NS1 antigen test or dengue
IgM antibody test (optional)
Confirmed dengue:
• Viral culture isolation
• PCR
PPS Revised Dengue Guidelines 2012

DENGUE FEVER
OLD
NEW
Case definition for Dengue Fever Hemorrhagic Fever (DHF)
The following must be all presented:
1. fever, or history of fever lasting 2-7 dayss, occasionally
biphasic
2. Hemorrhagic evidenced by at least one of the following:
a. (+) tourniquest test
b. Petechiae,ecchymosis, purpura
c. Bleeding from the mucosa, GIT, injection site or
other locations
d. Hematemesis or melena
3. Thrombocytopenia (100, 000 cells/mm3 or less)
4. Evidence of plasma leakage due to increased vascular
permeabilit, manifested by atleast one of the following:
a. A rise in the hematocrit equal to or greater than
20% above average for age, sex and popultion
b. A drop in the hematocrit following volume
replacement treatment equal to or greater than
20% of baseline.
c. Signs of plasma leakage such as pleural effusion
ascites and hypoproteinemia
Case definition for Dengue with warning signs
Lives or travel to dengue-endemic area with fever lasting for 2-
7 days, plus any one of the following:
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical signs of fluid accumulation
• Mucosal bleeding
• Lethargy, restlessness
• Liver enlargement
• Decreased or no urine output with in 6 hours
• Laboratory: increased in HCT and or decreasing platelet
Confirmed Dengue:
• Viral culture isolation
• PCR

DENGUE FEVER
OLD
NEW
Case definition for Dengue Shock syndrome (DSS)
All of the four criteria for the DHF must present, plus
evidence of circulatory failure manifested by:
• Rapid and weak pulse, AND
• Narrow pulse pressure (<20mmHg )
or
manifested by:
• Hypotension for age, AND
• cold clammy skin and restlessness
Case Definition for Severe Dengue
Lives in or travel to a dengue-endemic area with fever
2- 7 days and any of the above clinical manifestations
for dengue with or without warning signs, plus any of
the following
• Severe plasma leakage, leading to:
• shock
• Fluid accumulation with respiratory distress
• Severe bleeding
• Severe organ impairment
• Liver : AST or ALT≥1000
• CNS : e.g seizures, impaired consciusness
• Heart : e.g myocarditis
• Kidney e.g renal failure

DENGUE FEVER
OLD
NEW
Grading of Severity of DHF/DSS
• DHF Grade 1
Fever accompanied by non specific
constitutional signs and symptoms such as
anorexia, vominting abdominal pain, the only
hemorrhagic manifestatin is a (+) tourniquet
test and or easy bruising
• DHF Grade 2
Spontaneous bleeding in addition to
manifestatations of grade 1 patient usually in
the form of skin or other hemorrhages
• DHF Grade 3 (DSS)
Circulatory failure manifested by rapid, weak
pulse and narrowing of pulse pressure or
hypotension,with the presence of cold clammy
skin and restlessness.
• DHF Grade 4 (DSS)
Profound shock with undetectable blood
pressure or pulse

Course in the ER

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
shallow SC retractions
rales BLF
A: PCAP C
Dengue Fever (without warning signs)
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
PICTURE

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
REASONS FOR ADMISSION :
1. Moderate dehydration
2. Weak looking
3. Loss of appetite

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
DIET :
• Diet for AGE
• No dark color foods

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
Dengue Fever
P: ADMIT
Diet
Hydration
Diagnostics Nelson Textbook of Pediatrics 19th
ed
Treatment
ASSESSMENT OF DEGREE OF DEHYDRATION
MILD MODERATE SEVERE
Infant 5% 10% 15%
Adolescent 3% 6% 9%
Infants and young children Thirsty, alert, restless Thirst, restless or lethargic, irritable Drowsy, limp, cold, sweaty, comatose
Older children Thirsty, alert Thirst, alert Conscious, apprehensive, cold, sweaty,
cyanotic extremities
SIGNS AND SYMPTOMS
Tachycardia Absent Present Present
Palpable pulses Present Present Decreased
Blood pressure Normal Orthostatic hypotension Hypotension
Cutaneous perfusion Normal Normal Reduced and mottled
Skin turgor Normal Slight reduction Reduced
Fontanelle Normal Slightly depressed Sunken
Mucous membrane Moist Dry Very dry
Tears Present Present or absent Absent
Respirations Normal Deep, may be rapid Deep and rapid
Urine output Normal Oliguria Anuria and severe oliguria

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
HYDRATION :
Plain LR (20cc/k) fast drip

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
CBC 10/25
Hemoglobin 129
Hematocrit 0.38
WBC 4.10 ↓
Segmenters 0.65
Stabs 0.07
Lymphocytes 0.26
Monocytes 0.02
Platelets 283,000
Dengue NS1Ag
Positive

DIAGNOSTIC
• Nonstructural protein 1
• 2006 : test for dengue
by Bio Rad Laboratories and Pasteur Institute
• Allows rapid detection on the D1 illness
before antibodies appear D5 illness
• NS1 antigen as an early diagnostics marker in dengue
• Comparison :
– NS1 antigen : good sensitivity (70-100%) till D3 illness
– IgM : sensitivity of 0-50% till D3 illness
Dengue NS1 Ag
Singh et al DMID 2010 Sept; 68(1):50-4)

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
FINDINGS: Hazy infiltrates in right inner lung zone,
with confluency in right middle lobe
IMPRESSION : pneumonia right with consolidation,
right middle lobe

COURSE IN THE ER
DAY OF ADMISSION
S/O: CR 115 BP 90/60 O2 sat 98-99%
RR 33 T 37.8
weak-looking
dry lips
flushed skin
rales BLF
A: PCAP C
P: ADMIT
Diet
Hydration
Diagnostics
Treatment
TREATMENT :
• Cefuroxime 100 mkd
• Paracetamol 15 mkd

CEFUROXIME
• Class : Second generation Cephalosporins
• MOD : inhibit bacterial cell wall
• Coverage :
Gram (+) cocci : S. pneumonia
: S. pyogenes
: A. streptococci
Gram (-) cocci : N. gonorrhea
Gram (-) rods : Enterobacter aerogenes
: E. coli
: H. influenzae
: K. pneumoniae
: Proteus mirabilis
Katzung & Trevors Pharmacology 10th ed

COURSE IN THE WARD
HOSPITAL DAY (HD) 1 (D3 illness)
S/O: CR 120 BP 100/60 UO : 1.5 ckh
RR 26 T 39
weak–looking full and equal pulses
Rales, BLF CRT <2 sec
A: PCAP C
P: IVF : D5NSS 3.7 ckh
Labs : Repeat CBC w/ PLT
Meds: Cefuroxime (day 1)
Paracetamol 15mkd

COURSE IN THE WARD
HD 1 (D3 illness)
S/O: CR 120 BP 100/60
RR 26 T 39
A: PCAP C
Paracetamol 15mkd

COURSE IN THE WARD
HD 1 (D3 illness)
S/O: CR 120 BP 100/60
RR 26 T 39
A: PCAP C
Paracetamol 15mkd
CBC 10/25 10/26
Hemoglobin 129 122 ↓
Hematocrit 0.38 0.36 ↓
WBC 4.10 ↓
Segmenters 0.65
Stabs 0.07 ↑
Lymphocytes 0.26
Monocytes 0.02
Platelets 283,000 212,000 ↓

DENGUE
T : 39oC
CR 120
BP 100/60
RR 26
Full & equal pulses
CRT < 2sec
Weak-looking
UO : 1.5ckh
Hct : 0.38  0.36
Plt : 283212
COURSE OF ILLNESS

COURSE IN THE WARD
HD 2(D4 illness)
S/O: CR 120 BP 90/60 abdominal distention (AC 55cm)
RR 34 T 38.8 puffy eyelids
loose watery stools, 3x rales BLF
vomits, 3x
abdominal pain
UO : 1.3 ckh
A PCAP C
Dengue Fever (with warning signs)
P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT
Meds: Cefuroxime (day 2) repeat CBC
Paracetamol 15mkd TPAG
Omeprazole
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Omeprazole
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT
Omeprazole
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
S/O: CR 120 BP 90/60 abdominal distension (AC 55cm)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
Omeprazole
Albumin transfusion
Furosemide
STOOL EXAM WITH CONCENTRATION TECHNIQUE
10/27
1st specimen
10/27
2nd specimen
10/27
3rd specimen
MACROSCOPIC
Color Yellow Yellowish green Yellowish brown
Consistency Unformed Unformed Mucoid
MICROSCOPIC
Ova None seen None seen None seen
Cyst None seen None seen None seen
Trophozoites
None seen None seen None seen
Pus cells 0-1/hpf 0-1/hpf 0-1/hpf
RBC 0-1/hpf 0-2/hpf 0-1/hpf
Others Yeast cell: few
Stool exam with concentration technique

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
Omeprazole
Albumin transfusion
Furosemide
CBC 10/25 10/26
10 am
10/27
10am
Hemoglobin 129 122 ↓ 129 ↑
Hematocrit 0.38 0.36 ↓ 0.38 ↑
WBC 4.10 ↓
Segmenters 0.65
Stabs 0.07 ↑
Lymphocytes 0.26
Monocytes 0.02
Platelets 283,000 212,000 ↓ 194,000↓

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Omeprazole 20mg IV
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Omeprazole 20 mg IV
Albumin transfusion
Furosemide

OMEPRAZOLE
Class: Proton pump inhibitor
MOA : Suppress the secretion of hydrogen ions
into the gastric lumen
• Duration of action is approximately 24h

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Omeprazole
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
S/O: CR 120 BP 90/60 abdominal distention (AC 53 55cm)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
Omeprazole
Albumin transfusion
Furosemide

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
Omeprazole
Albumin transfusion
Furosemide
TPAG NV 10/26
Total protein 66-87 43.6 ↓
Albumin 38-54 22.71 ↓
Globulin 23-35 20.89 ↓
A/G 1.8:1-2.3:1 1.09:1↓

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
Omeprazole
Albumin transfusion
Furosemide

Albumin Transfusion
MOA: increases intravascular oncotic pressure
Indications:
hemorrhagic shock
nephrotic syndrome
burn
hypoalbuminemia
hypovolemia
emedicine.medscape.com

COURSE IN THE WARD
HD 2(D4 illness)
vomits, 3x
abdominal pain
A PCAP C
Dengue Fever
P: IVF: D5 NSS 3.7 4ckh 3.2 ckh Labs: Stool exam w/ CT
Omeprazole
Albumin transfusion
Furosemide

DENGUE
T 38.8
HR 120
BP 90/60
RR 34
CRT < 2 sec
vomiting
Abdominal distension
Abdominal pain
Hct 0.35  0.38
UO: 1.3 ckh
COURSE OF ILLNESS

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/50 AC 55 57 cm dec breath sounds, R
RR 69 T 38.6 cold clammy extremities
irritable mottled skin
weak pulse CRT > 2 sec
UO: 0.7 ckh
A: PCAP D
Dengue Hemorrhagic Fever III (SEVERE DENGUE)
Compensated shock
P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter
PNSS 20ck as fast drip hook to O2 via mask
Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT
Paracetamol Repeat TPAG D- Dimer
albumin transfusion repeat CBC repeat CXR
HCO3 correction ABG

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak-looking CRT > 2 sec
weak pulse
A: PCAP D
Compensated shock
PNSS 20ck as fast drip O2 via mask @ 6-7 lpm
HCO3 correction ABG

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
CRT > 2 sec
A: PCAP D
Compensated shock
HCO3 correction ABG

Dengue Case Classification & Levels of
Severity

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
A: PCAP D
Compensated shock
HCO3 correction ABG

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
A: PCAP D
Compensated shock
HCO3 correction ABG
CBC 10/25 10/26
10 am
10/27
10am
10/28
5am
Hemoglobin 129 122 ↓ 129 ↑ 154 ↑
Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑
WBC 4.10 ↓ 4.9
Segmenters 0.50 0.47
Stabs 0.07 ↑ 0.02
Lymphocytes 0.26 0.49 ↑
Monocytes 0.02 0.02
Platelets 283,000 212,000 ↓ 194,000↓ 172, 000 ↓

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
A: PCAP D
Dengue Hemorrhagic Fever III
Compensated shock
HCO3 correction ABG
TPAG NV 10/26 10/28
Total protein 66-87 43.6 ↓ 39.3 ↓
Albumin 38-54 22.71 ↓ 23.16 ↓
Globulin 23-35 20.89 ↓ 16.14 ↓
A/G 1.8:1-2.3:1 1.09:1 ↓ 1.43:1 ↓

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
A: PCAP D
Compensated shock
HCO3 correction ABG
ABG 10/28
pH 7.251
pCO2
14
PO2
112.5
O2 sat 97.6
HCO3
6
TCO2
6.4
BE -21.2
Metabolic acidosis

COURSE IN THE WARD
HD 3(D5 illness)
S/O: CR 164 BP 80/70 AC 55 57 cm
weak pulse
A: PCAP D
Dengue Hemorrhagic Fever III(SEVERE DENGUE)
Compensated shock
HCO3 correction ABG

RAPID ASSESSMENT
• Irregular respirations or rate >60
• Heart ranges:
– Child ≤2 yrs of age : <80/min or >180/min
– Child >2 yrs of age : <60/min or >160/min
• Poor perfusion with weak/absent distal pulses
• Increased work of breathing
• Cyanosis
• Altered consciousness
• Seizures
• Fever with petechiae
• Trauma
• Burns involving >10% of BSA

CBC Assess Categorize Decide / Act
Consciousness Irritable Respiratory Distress ;
Shock
• call for help
• activate emergency
system
• hook to pulse ox &
cardiac monitor
• O2 per face mask
• SPO2 monitoring
Breathing Increased effort
Circulation pale
COURSE IN THE WARD (4pm)
Initial Assessment

Primary Assessment
ABCDE Assess Categorize Decide / Act
Airway Maintainable Respiratory distress
Compensated shock
• O2 mask: 10 LPM
• IV double line
• PNSS 20 cc/kg fast
drip
• Transfer to ICU
• NPO
• Hgt monitoring
Breathing RR : 55/min
SPO2 : 95%
SC retractions
Rales
Circulation HR : 140
fair pulse
BP 80/50
CRT >2
Disability GCS 15 (E4M6V5)
Exposure Temp 39C

SAMPLE Assess Categorize Decide / Act
S/Sx irritable
tachypnea
Subcostal retractions
Rales, bilateral
tachycardia,
Abdominal distension
CRT > 2 sec
Respiratory distress
secondary to lung
parenchyma disease;
severe dengue with
compensated shock
• continue
medications
• continue
cardiac
monitoring
• continue SPO2
monitoring
• request for:
repeat CBC PC
PT APTT
D Dimer
Chest X ray
ABG
Allergies None
Medications Cefuroxime ; Paracetamol
Past Med Hx No PCV
Acute gastroenteritis 2013
PCAP A
(Nov 2013, Jan 2014, April
2014)
Last Meal 4 hours
Secondary Assessment

Events Respiratory distress
Worsened work of breathing
Respiratory distress
secondary to lung
parenchyma disease;
severe dengue with
compensated shock
• continue
medications
• continue
cardiac
monitoring
• continue SPO2
monitoring
• request for:
repeat CBC PC
PT APTT
D Dimer
Chest X ray
ABG

• BP 80/50, CR 140, RR 55, T 39OC
• pink palpebral conjunctivae, anicteric sclera, no alar flaring,
dry and pale lips and oral mucosa
• adynamic precordium, tachycardic, apex beat at 4th ICS left
mid clavicular line, no murmur
• equal chest expansion, subcostal retractions, rales both lung
fields
• distended abdomen
• fair and fast pulses, CRT > 2 seconds
• neuro exam: normal

Laboratory Tests Results
CBC I PC Hgb 130, hct 0.38, wbc 8.7, seg 0.32, stabs 0.08, lymph 0.59,
mono 0.01, platelet 175
Pro-thrombin Time 15 ↑
Control 11.21
INR 1.46
Protime Activity 51.5
APTT 78.3 ↑
Control 34.1
D- dimer 627.22 ↑
CXR progression of pneumonia right, mild to moderate pleural
effusion, right
ABG pH- 7.251 pCO2- 14 pO2- 112.5 O2 sat- 97.6 HCO3- 6 TCO2- 6.4
BE-(-)21.2
Tertiary Assessment

Findings :
Show progression of pneumonic
infiltrates in the right middle lobe
and homogenous density in the
right hemithorax obscuring the
right cardiac border and blunting
of the right costophrenic sulcus
with lateral ascending border
pneumonia
IMPRESSION :
progression of pneumonia right,
mild to moderate pleural
effusion, right

1st-12th hour of PICU stay
• awake, conscious, irritable
• VS: BP 80/50, CR 130, RR 40, T 38.9oC
• Subcostal retraction, rales
• abdominal distention
• full pulses, CRT < 2 seconds

CBC Assess Categorize Decide / Act
Consciousness Irritable Respiratory Distress/
failure
• call for help
• activate emergency
system
• continue O2
facemask
• continue SPO2
monitoring
Breathing labored breathing
Circulation pale
COURSE IN THE ICU (6am)13th hour
Initial Assessment

ABCDE Assess Categorize Decide / Act
Airway Non-Maintainable Respiratory distress
and failure 2° to lung
parenchymal disease
• intubate
• continue cardiac
monitoring
• continue SPO2
monitoring
Breathing RR : 65/min
SPO2 : 89%
SC retractions
Rales, decreased
breath sounds R
mid to base lung
Circulation HR : 168
full pulse
BP 80/50
CRT <2
Disability GCS 15 (E4M6V5)
Exposure Temp 39C
COURSE IN THE ICU (6am)
Primary Assessment

S/Sx irritable, weak-looking
tachypnea, increase work of
breathing (alar flaring
subcostal retractions),
decreased breath sounds mid
to base right lung field
tachycardia
Respiratory
distress/failure 2° to
lung parenchymal
disease
• shift
Cefuroxime to
Ceftriaxone
• continue
cardiac
monitoring
• continue SPO2
monitoring
• request for:
CKMB, Trop-I,
BUN, Crea,
Blood C&S,
USG
Allergies None
Medications Cefuroxime ; Paracetamol
Past Med Hx day I ICU
Last Meal 19 hours

Events Severe Respiratory distress
Desaturation
Worsened work of breathing
Respiratory
distress/failure 2° to
lung parenchymal
disease
• shift
Cefuroxime to
Ceftriaxone
• continue
cardiac
monitoring
• continue SPO2
monitoring
• request for:
CKMB, Trop-I,
BUN, Crea,
Blood C&S,
USG

• BP 80/50, CR 160, RR 55, T 39OC
• pink palpebral conjunctivae, anicteric sclera, no alar flaring,
dry and pale lips and oral mucosa
• adynamic precordium, tachycardic, apex beat at 4th ICS left
mid clavicular line, no murmur
• labored breathing, subcostal retractions, rales both lung
fields, decreased breath sounds mid to base right lung field
• distended abdomen
• full pulses, CRT < 2 seconds
• neuro exam: normal

Laboratory Tests Results
CKMB 58.1
Troponin I 0.05
BUN 3.07
Creatinine 34.5
BLOOD CS negative 5 days
ABG pH- 7.352 pCO2-30.7 pO2 -95.5 O2 sat- 97.1 HCO3- 16.7 TCO2-
17.6 BE-(-)8.9
CXR no significant change in the previously noted pneumonia,
pleural effusion on the right
Tertiary Assessment

COURSE IN THE ICU
There is no significant change in
the previously noted pneumonia
and pleural effusion in the right,
heart and the rest of the chest
finding are unchanged

COURSE IN THE ICU
DAY 5, 2nd PICU DAY
Problem: PCAP D, DHF III
S/O: CR 136 BP 90/60 AC 56 57 cm
RR 51 T 37. 9 Urine output: 0.7ckh
Petechial rash , face Urine Sp.G: 1.025
Rales BLF
A: PCAP D
Dengue Hemorrhagic Fever III ( SEVERE DENGUE)
P: Hydration: PNSS 10ck as fast drip Diet: milk feeding 2oz per OGT q 4h
7ckh
Labs : ABG
Meds: Ceftriaxone (day 1)
Amikacin (day 1)
Domperidone

LABORATORY
ABG 10/28 10/29 10/30
pH 7.251 7.352 7.362
pCO2 14 30.7 29.8
PO2 112.5 95.5 162.9
O2 sat 97.6 97.1 99
HCO3 6 16.7 17
TCO2 6.4 17.6 17.9
BE -21.2 -8.9 -8.6

COURSE IN THE ICU
DAY 6, 3rd PICU DAY
Problem: PCAP D, DHF III
S/O: CR 160 BP 90/60 AC 57 cm
RR 62 T 39 Urine output: 1.2 ckh
pale & dry lips
rales both lung field
A: PCAP D
P: Labs : repeat CBC Hydration : D5 IMB 5ckh to KVO
repeat PT, PTT
repeat D dimer
Meds: Ceftriaxone (day 2)
Amikacin (day 2)
Furosemide

CBC 10/25 10/26
10 am
10/27
10am
10/28
5am
10/28
2 pm
11/1
5am
Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ 151 ↓ 93 ↓
Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ 0.44 ↓ 0.28 ↓
WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 10.7↑
Segmenters 0.50 0.47 0.27 ↓ 0.40 ↑
Stabs 0.07 ↑ 0.02 0.05 0.04
Lymphocytes 0.26 0.4 ↑ 0.67 0.56 ↓
Monocytes 0.02 0.02 0.01
Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 194 ↑

LABORATORY
NV 10/28 11/1
Pro-thrombin
Time 10-14 sec 15 14.8
Control 11.21 11.23
INR 1.46 1.43
Protime Activity % 51.5 53.1
APTT 28-36 sec 78.3 ↑ 49.3
Control 34.1 34.7
D- dimer 100-446.8 ng/mL 627.22 ↑ 2973.21↑

COURSE IN THE ICU
DAY 7, 4th PICU
S/O: CR 173 BP 80/50 AC 57 cm 55cm
RR 65 T 39 O2 sat : 70% 98%
Alar flaring
Rales BLF
Puffy eyelids
A: PCAP D
pulmonary congestion
P: Mgt : Re-intubation 4.5 depth and 13 mm, mech vent set up
NPO
Labs : repeat CXR
ABG
Meds: Ceftriaxone (day 3) Furosemide IVF Heplock
Amikacin (day 3) Dobutamine

CHEST X RAY
Shows significant resolution of the
previously noted right sided leural
effusion, hazy infiltrates are seen in
the right mid and both lower lobes
Imp: significant resolution of right
sided pleural effusion, new
infiltrates on right mid and both
lower lobes

ABG 10/28 10/29 10/30 11/1
pH 7.251 7.352 7.362 7.457
pCO2 14 30.7 29.6 36.6
PO2 112.5 95.5 162.9 27
O2 sat 97.6 97.1 99 57.4
HCO3 6 16.7 17 26
TCO2 6.4 17.6 17.9 27.2
BE -21.2 -8.9 -8.6 2
LABORATORY

COURSE IN THE ICU
DAY 8
S/O: CR 160 BP 110/60 AC 55cm
RR 55 T 38.9
A: PCAP D
P: Mgt : OGT resumed
Meds: Ceftriaxone (day 4) MEROPENEM 60mkd
Amikacin (day 4)
Furosemide every 4h 8h
kalium durule every 8h

COURSE IN THE ICU
DAY 9
S/O: CR 128 BP 90/60 AC 55cm 53cm
RR 52 T 37.3
Rales BLF
No alar flaring
No SC retraction
A: PCAP D
P: Mgt : continued
Meds: Meropenem(day1)
Amikacin (day 5)
Furosemide every 8h
kalium durule every 8h

COURSE IN THE ICU
DAY 10
S/O: CR 180 BP 90/60 AC 55cm 53cm
RR 52 T 38.4 UO 3.5ckh
Pale conjunctivae
Pale & dry lips
A: PCAP D
P: Diagnostics: repeat CXR repeat CBC w/ PC urine KOH
repeat ABG serum Na, K
Meds: Meropenem(day2) salbutamol neb
Amikacin (day 6) dexamethasone
Furosemide every 8h
kalium durule every 8h-----12h

CHEST X-RAY
Partial clearing of both infiltration
right mid and both lower lobes
Imp: Partial clearing of both
infiltration right mid and both
lower lobes

LABORATORY
ABG 10/28 10/29 10/30 11/1 11/4
pH 7.251 7.352 7.362 7.457 7.399
pCO2 14 30.7 29.6 36.6 34.8
PO2 112.5 95.5 162.9 27 57.6
O2 sat 97.6 97.1 99 57.4 89.6
HCO3 6 16.7 17 26 21.7
TCO2 6.4 17.6 17.9 27.2 22.7
BE -21.2 -8.9 -8.6 2 -3.4

LABORATORY
CBC 10/25 10/26
10 am
10/27
10am
10/28
5am
10/28
2 pm
10/28
6 pm
11/1
5am
11/4
5am
Hemoglobin 129 122
↓
129 ↑ 154 ↑ 151 ↓ 130 93 ↓ 88 ↓
Hematocrit 0.38 0.36
↓
0.38
↑
0.46 ↑ 0.44 ↓ 0.38 0.28 ↓ 0.28
WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 11 6.7 ↓ 10.4 ↑
Segmenters 0.50 0.47 0.27 ↓ 0.32 0.40 ↑ 0.64
Stabs 0.07 ↑ 0.02 0.05 0.08 0.04 0.02 ↓
Lymphocytes 0.26 0.4 ↑ 0.67 0.59 0.56 ↓ 0.34 ↓
Monocytes 0.02 0.02 0.01 0.01
Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 175 194 ↑ 265 ↑

LABORATORY
Electrolytes NV 11/1
Sodium 132-152 mmol/L 142.9
potassium 3.60-5.30 mmol/L 5.04
URINE KOH No fungal elements

COURSE IN THE ICU
DAY 11
S/O: CR 160 BP 90/60 AC 53cm
RR 60 afebrile
O2 sat 78%
A: PCAP D
P: Meds: Meropenem(day 3) salbutamol neb
Furosemide every 8h
kalium durule every 8h-----12h
Vit A 100,000 , 2 cap SD
Zinc Sulfate started

COURSE IN THE ICU
DAY 12
S/O: CR 110 BP 90/60 AC 53cm
RR 35 afebrile
O2 sat 99%
A: PCAP D
P: Mgt : extubated FC removed
NGT removed----clear liquid diet w/SAP
Meds: Meropenem(day 4) salbutamol neb
Furosemide d/c
Kalium durule every 8h-----12h
Zinc Sulfate (day 1)

COURSE IN THE WARD
HD 13(D15 of illness)
S/O: CR 96 BP 90/60 decreased rales
RR 31 afebrile CRT <2 sec
O2 sat 99% UO : 1.4 ckh
Equal & full pulses
A: PCAP D resolving
Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved
P: Transferred to HDU ST. Martin
Meds: Meropenem(day 5)
Amikacin (day 9)
Kalium durule d/c
FeSO4 started

COURSE IN THE WARD
RR 31 afebrile
O2 sat 99%
A: PCAP D resolving
Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved
P: Transferred to HDU ST. Martin
Amikacin (day 9)
Kalium durule d/c
FeSO4 started

COURSE IN THE WARD
RR 31 afebrile
O2 sat 99%
A: PCAP D
P: Transferred to ST. Martin High Dependecy Unit
Amikacin (day 9)
Kalium durule d/c
FeSO4 started

COURSE IN THE WARD
S/O: CR 100 BP 90/60 UO : 1.4 ckh
RR 33 afebrile
decreased rales
comfortable
A: PCAP D
P:
Amikacin (day 10)
Zinc Sulfate ( day 3)
FeSO4 (day 1)
Clarithromycin 7.5mkd per orem

COURSE IN THE WARD
S/O: CR 99 BP 90/60 comfortable
RR 30 afebrile clear breath sounds
A: PCAP D
P:
Amikacin (day 11)
FeSO4 (day 2)
oral clarithromycin (day1)

COURSE IN THE WARD
S/O: CR 99 BP 90/60
RR 30 afebrile
comfortable
A: PCAP D
P: Diet: soft diet
Amikacin discontinued
FeSO4 (day 3)

COURSE IN THE WARD
S/O: Stable vital signs
A: PCAP D
P: Diet: soft diet
FeSO4 (day 3)
MAY GO HOME

Home Meds:
1. Clarithromycin 15mkd BID
2. FeSO4 10mkd OD
3. Zinc Sulfate 5ml OD

COMPLICATION
• Sequelae of dengue virus infection are rare
but may include the following:
– Cardiomyopathy
– Encephalopathy
– Hepatic injury
– Pneumonia
– Ophoritis/orchitis

PREVENT BREEDING
235
Cover water containers,
wells, and water tanks
tightly
Keep drains free from
blockage
Change the water in
vases and for aquatic
plants at least once a
week and leave no water
in the saucers
underneath the plants
Cover up tires before
disposal to prevent
water from collecting.
Dispose of unwanted
containers where water
may collect such as lunch
boxes and soft drink cans
into covered bins
Repair uneven surfaces
of the ground to prevent
water from collecting
Check whether there is
water collecting on the
tray under an air-
conditioner and in the
drainage system, and
remove stagnant water

PREVENT BITES
10/12/2010 236
Wear light-coloured and
long-sleeved clothing and
pants
Apply mosquito
repellents containing
DEET to exposed parts of
the body
Use mosquito nets or
screens when the room
is not air-conditioned
Avoid visiting
scrubby areas
Install screens on
windows and doors, or
place mosquito coils
/electric mosquito mats
/anti-mosquito liquid
near the windows

FINAL DIAGNOSES
• PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA D
• DENGUE HEMORRHAGIC FEVER III (SEVERE)

Pediatric Community Acquired Pneumonia

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