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7/29/2019 Dengue Pkd - Copy - Copy

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TAKLIMAT DENGGI PKD

13 February 2011


2/23

UNIT KAWALAN VEKTOR JABATANKESIHATAN NEGERI JOHOR

2

DURATION BETWEEN TIME OF ADMISSION AND DEATH


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CONTRIBUTING FACTOR 2008 JOHOR

16 CASES

Came in already too ill 8 cases

Delay in Mx / low index of suspicion 4 cases

Inappropriate fluid management: 3 cases

Unrecognized dengue infection:

3 cases

Failure to recognise DSS 2 cases


4/23


More than 95% registered cases was seen by

primary care before notification

Only 0.2% notification by primary care

Mean days for notification day 5 onset

Mean day for death day 5

Less than 20% cases were fogged within day 5onset


5/23


Note:

There is still a number of primary care doctors

(including in A&E)

reluctant to diagnose dengue

excuse of non specific symptoms(fever ,

myalgia, diarhhoea).

This despite efforts to educate on dengueamongst doctors in government as well as

private care


6/23


Rationale of CPG

Current Problems: Failure or delay in diagnosis (GP/OPD, Emergency Department,

ward)

Over emphasis on thrombocytopenia, Lack of emphasis on

interpretation of serial HCT values

Poor clinical monitoring for both out-patients and in-patients

Under-estimation of severity of disease and unable to

recognize warning signs and shock

Inappropriate fluid therapy

Inappropriate use of blood and blood products


7/23


REMEMBER

dengue for the purpose of early notification is

a totally clinical diagnosis

Mainly for early control n Mx

With current dengue situation in Johor

It is easier to say a patient has dengue (1+2

symptoms) than to prove he does not havedengue at the primary care level


8/23


WARNING SIGNS FOR DENGUE

Abdominal pain or tenderness

Persistent vomiting

Clinical fluid accumulation (pleural effusion, ascites)

Mucosal bleedRestlessness or lethargy

Liver enlargement > 2 cm

Laboratory : Increase in HCT with rapid decrease in

platelet


9/23


9

Pathophysiology of DHF - 1

Primary pathophysiological abnormality in DHFand DSS is an acute increase in vascular

permeability

Plasma leakage results in hemoconcentrationand hypovolemia or shock

Hypovolemia leads to reflex tachycardia and

generalised vasoconstriction


10/23


10

Clinical manifestations of vasoconstriction in

various systems are; Skin

coolness, pallor and delayed capillary refill time

Cardiovascular system

raised diastolic blood pressure and a narrowing pulse pressure Renal system

reducing urine output

Gastrointestinal system

vomiting and abdominal pain

Central nervous system lethargy, restlessness, apprehension, reduced level of consciousness

Respiratory system

tachypnoea (respiratory rate >20/min)

Pathophysiology of DHF - 2


11/23


11

Clinical course of dengue infection - Overview

Febrile

Phase

Critical

Phase

Recovery

Phase

Lasts for 2 7 days

Clinical features are indistinguishable between DF and DHF

Happens often after the 3rd day of feverClinical presentation depends on the presence and degree of plasma

leakage

Lasts for about 24-48 hours

In DHF patients plasma leakage stops and is followed by

reabsorption of extravascular fluid


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12

Critical Phase - 3

Clinical warning signs of severe dengue or high

possibility of rapid progression to shock


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14/23

Kes 1

Admitted from A & E on 13/01/11 : F ever - 5/7

Vomiting , diarrhoea and abdominal pain for

2/7 Petechial rashes .

No bleeding tendency.

There are reported cases of dengue andfogging activities in patients housing area.

Was seen in KK ABC prior to admission.


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In KK ABC

Patient went to KK ABC since day 2 of fever (10/01/2011 ) for FBC monitoring.

Serial FBC as below :

10/01/2011 : Hb 11.7/ HCT 35/ WBC 9.9/ PLT 246

12/01/2011 : Hb 12.8/ HCT 39/ WBC 3.2/ PLT 118

13/01/2011 : Hb 12.8/ HCT 37/ WBC 2.5/ PLT 46

Patient was given IV Dextrose Saline 1 pint atKK ABC prior to transferring patient to A & EHSAJB.


16/23

10/1/2011 (d2) 12/1/2011 (d4) 13/1/2011 (d5)

Hb11.7 12.8 12.8

HCT 35 39 37

TWBC 9.9 3.2 2.5

Platelet 246 118 46

0

50

100

150

200

250

300

AxisTitle

FBC trend in KK ABC


17/23

DAERAH

Bil

Penduduk

Kes

Denggi

2010

(mg 5)

IR 2010

Kes

Denggi

2011

(mg 5)

IR 2011

JB 1427831 214 15.0 171 12.0

KG 292611 11 3.8 31 10.6

MG 72151 0 0.0 4 5.5

BP 387677 7 1.8 15 3.9

LG 126810 6 4.7 4 3.2

SG 179874 34 18.9 5 2.0

PN 161459 2 1.2 3 1.9

KT 214018 24 11.2 2 0.9

MR 234480 10 4.3 2 0.9

KJ 240194 12 5.0 2 0.8

JUM 3337105 320 9.6 239 7.0

KADAR INSIDEN KES DENGGI MENGIKUT DAERAH JOHOR

SEHINGGA MINGGU 5/2011


18/23UNIT KAWALAN VEKTOR JABATAN KESIHATAN NEGERI JOHOR

PENCAPAIAN KPI IKUT DAERAH :

Sehingga Mg 5

DaerahJUMLAH

keseluruhan

kes dilapor

Bil kesdilapor oleh

KK

Bil kesdilapor oleh

swasta

JUMLAHdilapor

klinik

primer

%dilaporklinik

primer

JB 171 12 10 22 12.9

KJ 2 1 0 1 50.0

MR 2 0 1 1 50.0

LG 4 0 0 0 0.0

BP 15 2 1 3 20.0

KG 31 5 3 8 25.8

SG 5 0 1 1 20.0PN 3 1 1 2 66.7

KT 2 1 1 2 100.0

MG 4 0 0 0 0.0

J ohor 239 22 18 40 16.7


19/23

KES 2

This 25 year-old foreigner initially presented to EmergencyDepartment, Hospital ABC (EDHSI) on 25/01/2010 withcomplaints of low grade fever, myalgia, arthralgia,epigastric pain and reduced oral intake since Sunday23/01/2011. On examination, his pulse rate was 114 and

his blood pressure was 77/64mmHg. There was tendernessover the epigastric region. Blood investigations revealedWCC 3500; Hb 13.8g/dL, HCT 40.2% and Plt 107000. Afterhydration with 1 pint IV drip, his blood pressure improvedto 105/52mmHg. He was discharged home on the same

day with an instruction to repeat his FBC at the nearestKlinik Kesihatan the next morning.


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discharge from EDHSI on 25/01/2011, his

condition did not improve. However, he did

not go and repeat his FBC at the nearest KK as

instructed. He had reduced oral intake andcontinued to have epigastric pain; prompting

him to seek medical treatment at a GP clinic

(name unknown) on 27/01/2010 and KlinikMedic on 28/01/2010. On both occasions, he

was discharged home.


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On 29/01/2011, he was noted by his friend to begenerally weak and have reduced conscious level andverbal response. In view of his deteriorating condition,he was then taken to EDHSI by his supervisor. History

taken from his friend and supervisor revealed thatpatient had complained of epigastric pain and nauseabut there was no vomiting. There was no bleedingnoted. He was living in one of the shophouses atTaman XX and there was fogging at his neighbourhood

one week before his admission. There was no historyof jungle trekking, swimming in river or recent travel.


22/23

Take home messages

1. Dengue clinical n dynamic = PPP di KK main

peranan penting

1. Elak kematian

2. Aktiviti kawalan notifikasi

3. ****Nasihat pada pesakit & keluara1. Datang utk periksa

2. Datang kalau ada warning signs3. Minum air yg isotonik

2. Plasma leakage IVD bergantung pd fasa

penyakit


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3. Pemeriksaan darah FBC

Tahu interprete

Bandingkan dgn keaadaan fizikal pesakit

4. Kad pemantauan dijalankan

Simpan utk bukti & penambahbaikan

Negeri akan dtg audit

***Fu pesakit jika tak datang/pt not admitted

adakan pasukan

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