Dengue Hemorrhagic Fever

ไข้เลือดออกเดงกี่
(Dengue hemorrhagic fever, DHF)
========================================================
"เดงกี่มี 4 ตัว"

Dengue viral infection in Thailand = 4 types
Den 1/2/3/4
Den1 = see through out the year
Den2 = common
Den3 = common
Den4 = least common ( Less than 10% )
========================================================
Variety of symptoms
1)No Symptoms
2)Viral fever
3)Dengue fever ??????????
4)Dengue Heorrhagic fever
5)Dengue Shock Syndrome
========================================================
Dengue Hemorrhagic Fever (DHF)
F = Acute and Sustained Fever for 2-7 days
H = Hemorrhage

Clinical of bleeding :
//Positive Tourniquet test
//Petechiae
//Epistaxis
//Hemoptysis
//Hematemesis
//Bleeding per gum
//Hypermenorrhea

(Additional of clinical that is not included in the criteria)
(Hepatomegaly/Splenomegaly)
(Pain on palpation on Liver or Spleen)

Clinical of serum leakage :
//Pleural effusion
//Ascites

Lab of Bleeding :
//Platelet less than 100,000
//PLT less than 3 per OPF
(average from 10 oil field)

Lab of serum leakage :
//Hct rise 20% or more (esp Hct more than 45%)
//Low "Albumin/Globulin" in plasma
========================================================
Dengue Shock Syndrome

DSS = DHF + Shock

Shock =
//Quiet pulse
//Fast Pulse
//Pulse Pressure less than 20
//Capillary refil takes more than 2 seconds
//Pale Palms and soles
//Agitate
========================================================
เดงกี่ 4 ระดับ
DHF Severity

Stage1
//need action to see bleeding
//////Positive Tourniquet
//////Easily Bruising

Stage2
//Self Bleeding
//////Epistaxis
//////Hematemesis
//////Hempotysis
//////Hematochezia
//////PeteChiae
//////Hypermenorrhea
//////Bleeding per gum

Stage3
//Shock ( 3 เด้ง = shock แล้วเฟร่ย )
//////Pulse Pressure narrow
//////Pulse fast/quiet
//////Cap Refill more than 2 secs
//////Agitate
//////Cold Palms and Soles

Stage4
//Severe Shock ( Arrest นั่นเอง )
//////BP can't be assessed
//////Pulse can't be palpated
===================================================
Investigation

1)Tourniquet
//Use BP
//Width 2/3 of Arm length
//Push up to MID of Sys to Dias
(EG: 120/80 = Push Pressure up to 100mmHg)
//Left 5 mins
//Off BP
//Wait 1 minute
//Count Petechiae in 1 square inches
//Positive = more than 10 in 1x1 inches

(positive in Day 1-2-3 = 50%-70%-80% subsequently)

2)CBC
//indication for critical time is coming in 24 hours(time of losing fever)
//////WBC less than 5,000
//////Lympocyte increase
//////Atypical Lymphocyte increase
===================================================
3 Shot Of the disease

Shot(1):Fever
//Sustained fever Day 2-3/3-4
//so the critical time will be Day3-4/4-5
//Longer time of sustained fever is more common
//Associated symptoms during this time
/////Headache
/////Petechiae in Axillary area/upper/Lower extremities
/////Nausea and Vomiting
/////Anorexia
/////Abdominal Pain
/////Day 3 would come with Hepatomegaly and Pain on Palpation

Shot(2):Critical Shot (Fever down)
//Bleeding as mentioned earlier
//Plasma leakage as mentioned earlier
//Duration approximately 24-48 hours
//Treatment is to give IV-Fluid

Shot(3):Recovery shot (Convalescence Rash)
//Whitish in the middle of Confluent Petechial Rash (only 20% found)
//Others may have "Pruritis" without Convalescence Rash
//Sinus-Brady-arrhythmia
//Urine output increase
=======================================================
Follow up Lab
1)CBC : as mentioned
2)LFT
//AST more than 60 : Likely Dengue
//AST or ALT more than 200 :
Beware of Hepatic Encep/Hepatic Failure
=======================================================

EKG : Sinus Arrhythmia

Sinus Arrhythmia
= Each individual is sinus
= some group of faster rate
= some group of slower rate
= different between rate of each group
is more than 4 little boxes ( 0.16secs )
====================================
Individual Sinus

• P-wave positive in Lead I/II/avF
• P-wave negative in Lead avR/V1
• PR-interval less than 5 little boxes
• QRS complex follow P-wave
• QRS complex less than 3 little boxes

====================================
Happens when "Breathing"

Inspiration = Faster Rate
Expiration = Slower Rate
====================================

EKG : Sinus Bradycardia

Sinus Bradycardia
= sinus conduction + Slower Rate
=====================================
Slower Rate = Less than 60 bpm
=====================================
Sinus conduction
1)P-wave

• Positive in Lead I/II/avF
• Negative in Lead avR/V1
• Follow by QRS in every P-wave

2)PR-interval

• Less than 5 little boxes
• means no blockage

3)QRS complex

• Follows every P-wave
• Less than 3 little boxes

=====================================

EKG : Sinus Tachycardia

Sinus Tachycardia = Sinus conducting wave + faster Rate

=======================================

Faster Rate = More than 100 bpm

=======================================

Sinus conducting wave

1) P-wave

• Postitive in Lead I/II/avF


• Negative in Lead avR/V1


• Follow by QRS in every beat

2)PR-interval

• Less than 5 little box
  
• means no block
  

3)QRS

• follow every p-wave


• Less than 3 little boxes

=======================================

EKG : Normal sinus rhythm

What is the definition of normal EKG in my own word ?

Normal Sinus Rhythm

= Sinus conducting Rhythm

= Sinus conducting + Sinus Rate

===========================================

Sinus Rate = 60 - 100 bpm

===========================================

Sinus conducting

1) P-wave

• Positive in Lead I/II/avF
• Negative in Lead avR/V1
• Following by Fellow QRS complex of the same rate
• ( 60-100bpm)

2)PR-interval

• less than 5 little box
• means normal conduction from SA-node to AV-node
• ( They can travel along in time )

3)QRS complex

• Follow every P-wave
• Same rate to P-wave
• Less than 3 little box

======================================

Humbie's very first aim !!!

Today i just had Medical OSCE exam which was screwed up.

I then realized that it was because i haven't been paying enough attention to my career and realized i'd be such a bad bad doctor.

So for this occasion,

I swear that i'd read at least one topic a day.

And to share this to the world here.

On Blogger site.

Be witness, Enjoy

May Wisdom be with you all !