Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Sudden onset of fever (high grade)
Severe headache (retroorbital pain)
Myalgia (muscle aches)
Arthralgia (joint pain)
Malaise (general discomfort and fatigue)
Nausea and vomiting (may be present)
Rash (may appear later in the illness)
II. History of Present Illness:
Duration of symptoms
Travel history to dengue-endemic area within the past two weeks
Severity of symptoms (worsening or improvement)
Bleeding symptoms (easy bruising, nosebleeds, gum bleeding)
III. Past Medical History:
Underlying medical conditions (important for risk stratification)
Previous history of dengue fever (can increase risk of severe dengue)
IV. Social History:
Recent mosquito bites
Living conditions (factors that may increase mosquito exposure)
V. Physical Exam:
Vital signs (BP, HR, RR, Temp) – may be elevated with high fever
General appearance (illness appearance)
Skin exam:
Look for characteristic rash (maculopapular, appears after a few days)
Assess for petechiae (small red spots) – a sign of potential bleeding
Lymphadenopathy (lymph node enlargement) – may be present
VI. Laboratory Studies (consider as appropriate):
Complete blood count (CBC):
May show decreased white blood cell count, low platelets (thrombocytopenia) in severe cases.
Dengue virus serology:
IgM antibodies indicate recent dengue infection.
PCR testing may also be used for early diagnosis.
Hemoglobin and hematocrit:
May show signs of hemoconcentration (increased concentration of red blood cells) due to plasma leakage in severe dengue.
Liver function tests:
May be abnormal in severe dengue with liver involvement.
VII. Classification (based on WHO guidelines):
Dengue Fever (DF): Classic symptoms without warning signs.
Dengue with Warning Signs (DW): Classic symptoms with any of the following warning signs:
Severe abdominal pain
Persistent vomiting
Bleeding manifestations
Lethargy or restlessness
Liver enlargement
Rapidly rising hematocrit (despite fluid resuscitation)
Severe Dengue (SD): Severe plasma leakage leading to shock (dengue shock syndrome – DSS) or other severe complications (organ failure, bleeding).
VIII. Assessment:
Dengue fever suspected based on clinical presentation and travel history.
Severity classification (DF, DW, or SD) based on WHO criteria.
Assessment of hydration status and risk of bleeding.
Consideration of other diagnoses with similar symptoms (malaria, chikungunya).
IX. Plan:
Supportive care:
Intravenous fluids for hydration and to maintain blood pressure.
Pain management (antipyretics for fever, analgesics for muscle aches).
Electrolyte monitoring and correction.
Monitoring:
Close monitoring of vital signs, hydration status, and bleeding symptoms.
Repeat laboratory tests to assess disease progression.
Hospitalization:
Patients with severe dengue (SD) or those at high risk for complications require hospitalization and close monitoring.
Anticoagulants and NSAIDs are generally contraindicated due to bleeding risk.
X. Prognosis:
Discuss the prognosis based on the severity of illness. Dengue fever is usually self-limited in mild cases with prompt supportive care.
Early recognition and management of severe dengue are crucial to improve outcomes.
XI. Notes:
Educate the patient and caregiver about mosquito bite prevention measures.
Advise on warning signs of severe dengue and the importance of seeking immediate medical attention if they develop.
Document the patient’s understanding of the diagnosis, treatment plan, and follow-up instructions.
XII. Resources:
Consider providing patient education materials on dengue fever from reputable sources (e.g., World Health Organization (WHO), Centers for Disease Control and Prevention (CDC)).