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Monitoring and Treatment of Dengue in Clinic

Monitoring And Treatment Of Dengue In Clinic

Dengue fever is a systemic and dynamic disease, the clinical presentation depending on the different phases of the disease. After a person being bitten by an infected mosquito (usually 2-7 days), the illness begins abruptly and will be followed by 3 phases which is the febrile, critical and recovery phase. Therefore, a patient suspected to have Dengue fever will be assessed in a stepwise manner when he comes to the health clinic.

Stepwise Approach in Outpatient Management

Step 1: Overall Assessment

Patients may arrive in the clinic or emergency department with nonspecific complaints. Most times, the diagnosis will be suspected during the gathering of the history. It is important to ask about recent travel, the constitutional symptoms and if patient live in an outbreak area. The key is to obtain a good history and suspect the diagnosis early. After the history taking and clinical examination completed and the diagnosis of suspected dengue case is established, a confirmation test such as COMBO rapid test kit for NS1, IgM and IgG should be performed.

These are the questions should be ask to a patient when came with fever to a clinic or emergency department;

  1. History
  1. When did the fever/ illness start.
  2. Any other associated sign and symptoms.e.g.body ache, muscle pain, joint pain, headache, vomiting or diarrhoea.
  3. Can he/she drink or eat. Amount of fluid or volume taken.
  4. Assess for warning sign:
  5. Mucosal bleeding:
  6. Red spots or patches on the skin
  7. Bleeding from nose or gums
  • Vomiting blood
  1. Black coloured stools
  2. Heavy menstruation
  3. Severe stomach pain
  4. Frequent vomiting
  5. Pale, cold or clammy skin
  6. Drowsiness or irritability or change in mental state e.g. fits / dizziness
  7. Difficulty in breathing
  8. Laboratory investigation results: Increase in Haematocrit concurrent with rapid decrease in platelet count.
  9. Urine output (frequency, volume and time of last voiding)
  10. Other relevant history to differentiate from other diseases:
    1. Family or neighbourhood history of dengue
    2. Is patient staying in an outbreak area?
    3. Is there any fogging activities carried out near patients residential
    4. Jungle trekking and swimming in waterfall
    5. Recent travelling
    6. Existing diseases: e.g.Diabetic,Hypertension or Hepatitis
  1. Physical Examination
  1. Assess mental state e.g. consciousness, alertness or any fitting episode.
  2. Assess hydration status e.g. dry lips, coated tongue, skin, urine output (frequency, volume, time of last voiding)and paediatric patients look access for activeness or reduce tears.
  3. Assess vital status:
    1. Skin colour examples pink or pale
    2. Cold/warm extremities (hand and foot)
    3. Blood pressure within the normal range for the person
    4. Pulse rate and heart rate
  1. Look out for rapid breathing
  2. Check for stomach pain and tenderness
  3. Examine bleeding manifestation

Laboratory Investigations

In clinic where laboratory services available, the following tests should be done:

  1. Full Blood Count (FBC), Total white cell count (WCC),Haematocrit (HCT),and Platelet count
  2. Dengue combo Rapid Test kit : NS1Ag ,Ig M,& Ig G

Doctor/clinician will use special clerking sheet for all Dengue suspected cases (Table1). The information will include patients’ demographic data, history and clinical manifestations so that easier to put the diagnosis, disease staging and severity assessment.

Table 1: Dengue Clerking Sheet

Dengue Clerking Sheet

Source: http://www.moh.gov.my/index.php/pages/view/989

Step 2: Diagnosis, disease staging and severity assessment

Based on patient’s history, physical examination, and laboratory investigation, the doctor or clinician will determine:

  1. Dengue diagnosis whether provisional or confirmed
  2. The phase of dengue illness.If dengue is suspected whether febrile, critical or recovery phase
  3. The hydration and vital status of patient whether in shock or not
  4. Whether the patient requires admission and referral to hospital or can be treated as outpatient in clinic

Step 3: Plan of management

  1. Any suspected or confirmed dengue case is compulsory to be Notify to nearest district health office via phone followed by disease notification form Health 1 within 24 hours after the diagnosis made.
  2. If admission is indicated, stabilise the patient at primary care before transfer.
  3. If admission is not indicated, daily or more frequent follow up is necessary until the discharge by the doctor
  4. Dengue monitoring record (TABLE 2) will be given to patient and to be used for outpatient care.

Dengue Monitoring Record

  1. Dengue monitoring record will be given to the patient with suspected or confirmed Dengue diagnosis.
  2. Details regarding temperature, blood pressure, pulse, haematocrit, white blood count and platelet should be written in the card by the attending doctor/medical health assistance so that all relevant information is available for the subsequent follow up.

Daily follow up is important for dengue patient until discharge by the doctor, to avoid any complication or death.

Table 2: Dengue Monitoring Record Card

Front view:

Dengue Monitoring Record Card

Back view:

Dengue Monitoring Record Card2

Dengue Monitoring Record Card3

Source: http://www.moh.gov.my/index.php/pages/view/989

Reference:

  1. Clinical Practice Guidelines (CPG) Management ofDengue Infection in Adults (Revised 2nd Edition) (2010).
  2. http://www.who.int/csr/resources/publications/dengue/Denguepublication/en/ Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva: World Health Organization.
  3. http://www.cdc.gov/dengue/resources/DENGUE-clinician-guide_508.pdf
  4. http://www.cdc.gov/dengue/clinicalLab/index.html Dengue Guidelines for Diagnosis, Treatment, Prevention and Control WHO 2009

 

Last Reviewed 25 November 2015
Writer Dr Gunenthira Rao A/L Subbarao
Translator Dr Gunenthira Rao A/L Subbarao
Accreditor Dr Kamaliah Binti Mohamad Noh