Tuesday, March 9, 2010

CASE STUDY

Actual Findings Normal Findings Analysis
White blood cells 1.4x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 1.88x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 5.5 g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 16.1% 40-52% Decreased due to poor oxygen supply
Platelet count 24x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 5.5 40-70% Neutropenia
Lymphocytes 91.6 19-48% Increased due to the body’s increased immune system
Eosinophils 0.2 2-8% Decrease due to disease process
Monocytes 2.7 3-9% Decrease
Basophils 0.0 0-5% Normal
Hematology Reports
February 24, 2010
PT
INR- 1.06
Patient-13.6
Control-15.5
%activity-88.5
Thromboplastin Time
Patient (APTT) 32.1
Control 31.6

February 24, 2010
7:03 PM








February 27, 2010
11:08 AM
Actual Findings Normal Findings Analysis
White blood cells 1.3x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 1.99x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 5.59g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 17.4% 40-52% Decreased due to poor oxygen supply
Platelet count 13x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 7.5 40-70% Neutropenia
Lymphocytes 84.6 19-48% Increased due to the body’s increased immune system
Eosinophils 0.4 2-8% decreased due to disease process
Monocytes 6.9 3-9% Normal
Basophils 0.9 0-5% Normal



















Actual Findings Normal Findings Analysis
White blood cells 1.8x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 2.25x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 6.9g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 19.9% 40-52% Decreased due to poor oxygen supply
Platelet count 8x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 6.4 40-70% Neutropenia
Lymphocytes 85.6 19-48% Increased due to the body’s increased immune system
Eosinophils 0.1 2-8% Decrease due to disease process
Monocytes 7.5 3-9% Normal
Basophils 8.4 0-5% Increase due to inflammatory response
February 27, 2010
11:37 PM
















Actual Findings Normal Findings Analysis
White blood cells 1.8x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 2.24x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 7.5 g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 22.7% 40-52% Decreased due to poor oxygen supply
Platelet count 12x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 6.7 40-70% Neutropenia
Lymphocytes 85.9 19-48% Increased due to the body’s increased immune system
Eosinophils 0.2 2-8% Decreased due to disease process
Monocytes 5.7 3-9% Normal
Basophils 1.5 0-5% Normal
February 28, 2010
12:27 PM


















March 1, 2010
5:54 AM

Actual Findings Normal Findings Analysis
White blood cells 2.0x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 2.21x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 6.8g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 19.5% 40-52% Decreased due to poor oxygen supply
Platelet count 12x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 5.1 40-70% Normal
Lymphocytes 88.8 19-48% Increased due to the body’s increased immune system
Eosinophils 0.1 2-8% Decreased due to disease process
Monocytes 5.1 3-9% Normal
Basophils 0.9 0-5% Normal



















Actual Findings Normal Findings Analysis
White blood cells 2.9x10^g/L 4.8-10.8x10^g/l Decreased due to inadequate inflammatory defenses to suppress infection and humoral immunity takes place
Red blood cells 2.081x10^12/L 4.7-6.1x10^12/L Decreased due to anemia
Hemoglobin 6.6g/dL 13-17 g/dL Decreased due to poor oxygen supply
Hematocrit 18.6% 40-52% Decreased due to poor oxygen supply
Platelet count 134x10^3/uL 150-450x10^3/uL Hemolysis
Differential count
Neutrophils 10 40-70% Neutropenia
Lymphocytes 81.3 19-48% Increased due to the body’s increased immune system
Eosinophils 0.3 2-8% Decrease due to disease process
Monocytes 6.1 3-9% Normal
Basophils 2.3 0-5% Normal

March 2, 2010
9:28 PM












Urinalysis

February 26, 2010

Physical

Color - Yellow
Transparency -Hazy
Specific gravity – 1.005
Reaction- 8
Sugar- Negative
Protein- Negative

Microscopic

RBC-3.4
WBC-3.4
Epithelial cells- Few
Bacteria- None
Crystal- Few



Biochemical

Urobilinogen +1
Nitrate (-)
Blood +1
Bilirubin (-)
Ketone (-)
Leukocyte (-)














ANATOMY AND PHYSIOLOGY


BLOOD

Blood is considered the essence of life because the uncontrolled loss of it can result to death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body.

Functions of Blood:
>transports gases, nutrients, waste products, and hormones
>involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and electrolyte levels
>protects against diseases and blood loss

PLASMA

Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients, gases, waste products, and regulatory substances.

Plasma volume remains relatively constant. Normally, water intake through the GIT closely matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen.

FORMED ELEMENTS

Cell Type Description Function
Erythrocytes (RBC) Biconcave disk, no nucleus, 7-8 micrometers in diameter Transport oxygen and carbon dioxide
Leukocytes (WBC):

Neutrophil






Basophil





Eosinophil




Lymphocyte







Monocyte

Spherical cell, nucleus with two or more lobes connected by thin filaments, cytoplasmic granules stain a light pink or reddish purple, 12-15 micrometers in diameter

Spherical cell, nucleus, with two indistinct lobes, cytoplasmic granules stain blue-purple, 10-12 micrometers in diameter

Spherical cell, nucleus often bilobed, cytoplasmic granules satin orange-red or bright red, 10-12 micrometers in diameter

Spherical cell with round nucleus, cytoplasm forms a thin ring around the nucleus, 6-8 micrometers in diameter




Spherical or irregular cell, nucleus round or kidney or horse-shoe shaped, contain more cytoplasm than lymphocyte, 10-15 micrometers in diameter

Phagocytizes microorganism






Releases histamine, which promotes inflammation, and heparin which prevents clot formation


Releases chemical that reduce inflammation, attacks certain worm parasites


Produces antibodies and other chemicals responsible for destroying microorganisms, responsible for allergic reactions, graft rejection, tumor control, and regulation of the immune system

Phagocytic cell in the blood leaves the circulatory system and becomes a macrophage which phagocytises bacteria, dead cells, cell fragments, and debris within tissues
Platelet Cell fragments surrounded by a cell membrane and containing granules, 2-5 micrometers in diameter Forms platelet plugs, release chemicals necessary for blood clotting

PREVENTING BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are lost, death can occur.

BLOOD CLOTTING

Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids.

The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury however, the clotting factors are activated to produce a clot. This is a complex process involving chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue can result in their activation. Chemicals released from injured tissues can also cause activation of clotting factors. After the initial clotting factors are activated, they in turn activate other clotting factors. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

CONTROL OF CLOT FORMATION

Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming.

CLOT RETRACTION AND DISSOLUTION

After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged area and the formation of the new connective tissue. In addition, epithelial cells around the wound divide and fill in the torn area.

The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.





Pathophysiology Dengue Fever

Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of this serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans.

INTUBATION PERIOD: Uncertain. Probably 6 days to 10 days

PERIOD OF COMMUNICABILITY: Unknown. Presumed to be on the 1st week of illness when virus is still present in the blood

CLINICAL MANIFESTATIONS:

First 4 days:
>febrile or invasive stage --- starts abruptly as high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctival infection and epistaxis
4th to 7th day:
>toxic or hemorrhagic stage --- lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from GIT in the form of melena; unstable BP, narrow pulse pressure and shock; death may occur; vasomotor collapse
7th to 10th day:
>convalescent or recovery stage --- generalized flushing with intervening areas of blanching appetite regained and blood pressure already stable

MODE OF TRANSMISSION:

Dengue viruses are transmitted to humans through the infective bites of female Aedes mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission.

Humans are the main amplifying host of the virus. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time as they have fever. Aedes mosquito may have acquired the virus when they fed on an individual during this period. Dengue cannot be transmitted through person to person mode.

CLASSIFICATION:

1. Severe, frank type
>flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death
2. Moderate
>with high fever but less hemorrhage, no shock present
3. Mild
>with slight fever, with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or typical cases
GRADING THE SEVERITY OF DENGUE FEVER:

Grade 1:
>fever
>non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain
>absence of spontaneous bleeding
>positive tourniquet test
Grade 2:
>signs and symptoms of Grade 1: plus
>presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:
>signs and symptoms of Grade 2 with more severe bleeding: plus
>evidence of circulatory failure: cold, clammy skin, irritability, weak to compressible pulses, narrowing of pulse pressure to 20 mmhg or less, cold extremities, mental confusion
Grade 4:
>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE:

>all persons are susceptible
>both sexes are equally affected
>age groups predominantly affected are the pre-school age and school age
>adults and infants are not exempted
>peak age affected: 5-9 years old

DF is sporadic throughout the year. Epidemic usually occurs during rainy seasons (June – November). Peak months are September – October. It occurs wherever vector mosquito exists.

DIAGNOSTIC TEST:

Tourniquet test
>Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes.
>Release cuff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa.
>Count the number of petechiae inside the box. A test is positive when 20 or more petechiae per suare are observed.



DENGUE PREVENTION:
There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites when traveling to areas where dengue occurs and when in U.S. areas, especially along the Texas-Mexico border, where dengue might occur. Eliminating mosquito breeding sites in these areas is another key prevention measure.
Avoid mosquito bites when traveling in tropical areas:
 Use mosquito repellents on skin and clothing.
 When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and long pants tucked into socks.
 Avoid heavily populated residential areas.
 When indoors, stay in air-conditioned or screened areas. Use bednets if sleeping areas are not screened or air-conditioned.
 If you have symptoms of dengue, report your travel history to your doctor.
Eliminate mosquito breeding sites in areas where dengue might occur:
 Eliminate mosquito breeding sites around homes. Discard items that can collect rain or run-off water, especially old tires.
 Regularly change the water in outdoor bird baths and pet and animal water containers.








Personal Data



Name: R.B.A

Age: 34 years old

Address: Gate 10 Area-B Parola Compound, Tondo Manila

Sex: Male

Civil status: Married

Nationality: Filipino

Birthday: September 11, 1975

Birthplace: Manila City

Religion: Roman Catholic

Occupation: Trucking laborer

Date of admission: February 24, 2010

Time of admission: 11:40 AM

Chief complain: fever

Tentative diagnosis: dengue hemorrhagic fever grade III

Final diagnosis: dengue hemorrhagic fever grade III

Admitting Physician: Dra. Coraleah C. Lim












Clinical History



Past medical history

(-) previous hospitalization
(-) allergy to food and drug
(-) dengue
(-) asthma


Family history

(+) Hypertension- mother
(-) Diabetes Mellitus
(-) Cancer
(-) asthma


Occupation and Environment

(+) Canal


History of present illness


Five days PTC, patient had fever undocumented, self medicated with paracetamol and Alaxan affording temporary relief. Four days PTA, still with on and off fever, now associated with nosebleeding and gumbleeding, and throat pain and difficulty of swallowing. Few hours PTC, consulted a nearb hospital, a tourniquet test was done and revealed (+), prompted to seek consult to San Lazaro Hospital.










Physical Examination

Date assessed: February 24, 2010 7:03 PM
General assessment: conscious and coherent
Initial Vital signs: T: 38.6 C P: 117 beats/min R: 23 breaths/min BP: 80/50 mmHg


Head: Normocephalic


Eyes: Anicteric sclera, pink palpebral conjunctiva


ENT :(-) nasal discharge


Neck: stipple neck (-) cervical lymphadenopathy


Heart: adynamic precordiunm , no murmur , normal rate , regular rhythm


Chest: symmetrical chest expansion (-0 retraction


Lungs: clear breath sounds


Abdomen: flat, no tenderness, normoactive bowel sound


Extremities: (+) tourniquet test, full, equal pulse

External genitalia: essentially normal, no discharge


Neurological: No deficit

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