Dengue fever physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The physical examination in Dengue fever should be directed to ward identifying signs that the patient has severe disease warranting admission or in-hospital observation.

Vital Signs

Tachycardia, postural hypotension, and hypotension could indicate dehydration. Patients who are triaged to home management should urinate at least every 6 hours.

Mental Status

Lethargy

Abdomen

▸ Group criteria

❑ Patients with any of the warning signs:

  ❑ Abdominal pain or tenderness
  ❑ Persistent vomiting
  ❑ Clinical fluid accumulation
  ❑ Mucosal bleed
  ❑ Lethargy, restlessness
  ❑ Liver enlargment >2 cm
  ❑ Increase in hematocrit with rapid decrease in platelet count

▸ Laboratory tests

▸ Management

▸ Monitoring

Group C (Require emergency treatment)

▸ Group criteria

❑ Patients with any of the warning signs:

  ❑ Abdominal pain or tenderness
  ❑ Persistent vomiting
  ❑ Clinical fluid accumulation
  ❑ Mucosal bleed
  ❑ Lethargy, restlessness
  ❑ Liver enlargment >2 cm
  ❑ Increase in hematocrit with rapid decrease in platelet count

▸ Laboratory tests

▸ Management The physical examination should include: • assessment of mental state; • assessment of hydration status; • assessment of haemodynamic status (Textbox D); • checking for quiet tachypnoea/acidotic breathing/pleural effusion; • checking for abdominal tenderness/hepatomegaly/ascites; • examination for rash and bleeding manifestations; • tourniquet test (repeat if previously negative or if there is no bleeding manifestation).

• 

  The above picture is a rash typically associated with Dengue fever.

Appearance of the Patient

The diagnosis of dengue is usually made clinically. The classic picture is high fever with no localising source of infection, a petechial rash with thrombocytopenia and relative leukopenia.

There exists a WHO definition of dengue haemorrhagic fever that has been in use since 1975; all four criteria must be fulfilled:

1. Fever
2. Haemorrhagic tendency (positive tourniquet test, spontaneous bruising, bleeding from mucosa, gingiva, injection sites, etc.; vomiting blood, or bloody diarrhea)
3. Thrombocytopaenia (<100,000 platelets per mm³ or estimated as less than 3 platelets per high power field)
4. Evidence of plasma leakage (hematocrit more than 20% higher than expected, or drop in haematocrit of 20% or more from baseline following IV fluid, pleural effusion, ascites, hypoproteinaemia)

Dengue shock syndrome is defined as dengue haemorrhagic fever plus:

• Weak rapid pulse,
• Narrow pulse pressure (less than 20 mm Hg)

or,

• Hypotension for age;
• Cold, clammy skin and restlessness.