Presenting History
In children presenting with suspected Dengue or Dengue Shock Syndrome (DSS), establish the day of illness, pinpoint the timing of defervescence, screen for the 7 WHO warning signs, and evaluate peripheral perfusion.
- Chronological Phases of Dengue:
- Febrile Phase (Days 1 to 3-4): Did high continuous fever ($103-104^\circ\text{F}$) begin acutely with retro-orbital headache, facial flushing, and severe body aches ("breakbone fever")?
- Timing of Defervescence: On which day did the fever drop to normal or subnormal?
- Onset of Shock at Defervescence: Did the child become cold, clammy, pale, restless, and limp immediately as the fever came down (hallmark of Critical / Plasma Leakage Phase)?
- WHO Dengue Warning Signs Screen:
- Is there severe, continuous, unremitting abdominal pain?
- Is there persistent vomiting ($\ge 3$ episodes in 24 hours)?
- Has there been rapid abdominal distension (ascites) or breathlessness (pleural effusion)?
- Is there bleeding from the nose (epistaxis), gums, vomit (hematemesis), or black stools (melena)?
- Has the child become abnormally restless, lethargic, or confused?
- Is there marked reduction in urine volume and frequency (oliguria $<0.5\text{ mL/kg/hr}$)?
- Convalescent Phase Signs:
- In recovering children, has the "isles of white in a sea of red" petechial convalescent rash appeared with sudden return of appetite and brisk urination?
Negative History (3C 1D Framework)
| Category | Pertinent Negative Question | Rationale / Significance |
|---|---|---|
| Causes | Past Dengue Episode: Inquire regarding prior episodes of dengue fever in the child. Household Contacts: Check for family or neighborhood cluster cases of dengue. | Secondary dengue infection carries a 20- to 40-fold higher risk of Severe Dengue via Antibody-Dependent Enhancement (ADE). Demonstrates epidemic vector exposure. |
| Complaints (Differentiating) | Bacterial Sepsis: Shock in sepsis is typically hyperdynamic early; dengue shock characteristically develops at defervescence with narrow pulse pressure. Malaria: No shivering chills, rigors, or dark tea-colored urine. | Differentiates septic shock from dengue plasma leak shock. Differentiates from falciparum malaria and hemoglobinuria. |
| Complications | Severe Internal Hemorrhage: No sudden hematocrit drop with refractory shock, massive hematemesis, or melena. Severe Organ Impairment: No jaundice, AST/ALT $>1000\text{ U/L}$ (dengue hepatitis), coma, or myocarditis. Fluid Overload: No tachypnea with pink frothy sputum or bilateral crepitations during recovery. | Occult GI bleeding requires emergency whole blood transfusion. Defines Severe Dengue with organ failure. Iatrogenic hypervolemic pulmonary edema results from excessive crystalloids. |
| Differentials | Meningococcemia: No fulminant necrotic purpura or neck stiffness. Scrub Typhus: No pathognomonic eschar or generalized lymphadenopathy. | Rules out acute meningococcal sepsis. Rules out rickettsial capillary leak. |
Other Relevant History
- Medication History: Strict inquiry regarding intake of NSAIDs (Ibuprofen, Mefenamic acid, Aspirin) which severely exacerbate platelet dysfunction and trigger catastrophic upper gastrointestinal bleeding. (Only Paracetamol is safe in dengue).
History Summary
"Master/Miss `Patient Name`, a `Age` old `male/female` child, `Birth Order` born of a `consanguineous/non-consanguineous` marriage from `City, State`, presented on Day `Day of illness` of illness with acute defervescence accompanied by severe continuous abdominal pain, persistent vomiting, epistaxis, cold clammy extremities, restlessness, and oliguria, following 4 days of high continuous fever, with a past history of `Primary dengue / Family cluster`, in the absence of massive GI hemorrhage or seizures.
In view of the acute defervescence shock, severe plasma leakage warning signs, and hemoconcentration, I would like to consider a provisional diagnosis of Severe Dengue with Dengue Shock Syndrome (Compensated Shock) in the critical phase, requiring emergent isotonic crystalloid fluid resuscitation and micro-hematocrit monitoring."
General & Head-to-Toe Examination
- Hemodynamic & Shock Assessment (Crucial Triad):
- Heart Rate: Assess for rapid, thready peripheral pulses (radial, dorsalis pedis).
- Blood Pressure & Pulse Pressure:
- Measure systolic and diastolic blood pressure.
- Calculate Pulse Pressure ($= \text{Systolic} - \text{Diastolic}$): A pulse pressure $\le 20\text{ mmHg}$ (e.g., $90/72\text{ mmHg}$) is the pathognomonic hallmark of Compensated Shock!
- If systolic BP is unrecordable or below age-appropriate 5th centile, classify as Decompensated / Hypotensive Shock.
- Capillary Refill Time (CRT): Measure over sternum or finger pad ($>2-3\text{ seconds}$ indicates poor perfusion); note cold, clammy, mottled extremities.
- Bleeding & Cutaneous Signs:
- Inspect for petechiae, ecchymoses, dried blood in nostrils, and gingival oozing.
- Perform Tourniquet Test if no overt bleeding is present (positive if $\ge 10-20\text{ petechiae/square inch}$).
- Fluid Accumulation Signs:
- Periorbital puffiness, bilateral pedal edema.
Systemic Examination
Respiratory System
- Check for tachypnea and respiratory distress; percuss for Right-sided Pleural Effusion (stony dullness at right base); auscultate for decreased breath sounds.
Abdomen
- Symmetrically distended; diffuse tenderness maximal in epigastrium and right hypochondrium; palpate for tender Hepatomegaly (measure cm below costal margin); elicit shifting dullness (ascites).
Central Nervous System
- Assess sensorium: Restlessness, lethargy, or GCS score; check for meningismus or focal deficits.
Final Summary & Diagnosis
"A `Age` old `male/female` child presenting on Day `Day` of illness with acute defervescence shock, cold clammy extremities, prolonged CRT (`CRT in sec`), tachycardia (`HR in bpm`), narrow pulse pressure (`BP in mmHg`, $\Delta \le 20\text{ mmHg}$), tender hepatomegaly, right-sided pleural effusion, and ascites.
My final diagnosis is Severe Dengue: Dengue Shock Syndrome (Compensated Shock) in the critical plasma leakage phase, with severe plasma leakage and thrombocytopenia, without decompensated hypotensive shock or massive gastrointestinal hemorrhage, requiring immediate WHO-guided fluid resuscitation."