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Our Lady of Fatima University

College of NursingRegalado, Quezon City

A Case Study onDengue Fever

In Partial Fulfillment of the Requirements in

Nursing Care Management 102ARelated Learning Experience

Presented by:BSN 2Y2-4Group 21

Gianchand, Olivia P.Manuel, Janine M.

Second SemesterS.Y 2011-2012

I. Introduction

Dengue Fever is an infectious disease carried by mosquitoes and caused by any 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. This disease

used to be called “break-bone” fever because it sometimes causes severe joint and muscle pain

that feels like bones are breaking, hence the name, there may also be gastritis associated to

abdominal pain, nausea, vomiting, or diarrhea. 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 Aedesaegypti or

Aedesalbopictus mosquito through the transmission of the viruses to humans by the bite of an

infected mosquito. Dengue cannot be transmitted or directly spread from person to person. It can

be transmitted by AedesAegypti mosquito to humans usually attacking during the day and

shortly after the rainy season in tropical and subtropical areas of Africa, Southeast Asia and

China, India, Middle East, Caribbean and Central and South America, Australia and the South

and Central Pacific. After virus incubation for eight to 10 days, an infected mosquito is capable,

during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female

mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs)

transmission, but the role of this in sustaining transmission of the virus to humans has not yet

been defined.

The incidence of dengue has grown dramatically around the world in recent decades.

Some 2.5 billion people, two fifths of the world's population, are now at risk from dengue. WHO

currently estimates there may be 50 million dengue infections worldwide every year. There is no

specific treatment for dengue fever. Health experts have known about dengue fever for more

than 200 years.

II. Objectives

General:

This study aims to identify and determine the general health problems and needs of the

patient with an admitting diagnosis of Dengue Fever. It also intends to help patient promote

health and medical understanding of such condition through the application of the nursing skills.

Specific:

1.) To raise the level of awareness of patient on health problems that she may encounter.

2.) To facilitate patient in taking necessary actions to solve and prevent the identified

problems on her own.

3.) To help patient in motivating her to continue the health care provided by the health

workers.

4.) To render nursing care and information to patient through the application of the

nursing skills.

III. Patient’s Profile

A. Biographical Data

1. Name: Ms. C.T.

2. Address: Barangay 309,Sampaloc, Manila

3. Age: 10

4. Birthdate: June 19,2001

5. Sex: Female

6. Race: Filipino

7. Marital status: Single

8. Occupation: N/A

9. Religion: Catholic

10. Health Care financing and usual source of Medical Care:

Supported by the patient’s parents

A. Working Diagnosis

Dengue Fever Syndrome

B. Chief Complaint and Reason for Visit:

Fever

C. Past Medical History:

Our patient was never admitted to the hospital. Until she was diagnosed with dengue

fever syndrome. Before Ms. C.T. was diagnosed to have dengue, she had fever and was given

Paracetamol by her mother at home.

D. Family History of Illness:

The patient has a family history of hypertension. According to her, both of her parents

have hypertension.

E. History of Present Illness:

Four days prior to admission, the patient had on and off fever. She would usually have

fever in the afternoon. As a remedy, the patient’s mother gave Paracetamol to reduce her body

temperature. Aside from fever, Ms. C.T. also experienced abdominal pain, headache, general

flushing of the skin and vomiting.

As the signs and symptoms persisted, her mother decided to bring her to the hospital.

After the physical assessment and diagnostic tests, Ms. C.T. was diagnosed to have Dengue

Fever Syndrome by the attending physician.

IV. Physical Assessment

Assessment Normal Findings Actual Findings InterpretationBody Build,

Height & WeightProportionate Varies With

Lifestyle

Proportionate Varies With Lifestyle

Proportionate body there is no evidence of physical

problemsPosture And Gait Stands normally Stands normally Relaxed, erect posture;

coordinated movementBody And Breath

OdorNo Body Or Breath

OdorNo Body Or Breath

OdorProper hygiene

maintenanceSigns Of Distress No Distress Noted distress noted Because of lack of sleep,

distress notedAttitude Cooperative Cooperative Thinks normally, proper to

the situationAffect Or Mood Appropriate To The

SituationAppropriate To The

SituationShe acts and think

normally appropriate to the situation

Quantity, Quality And Organization

Of Speech

Understandable, Moderate Pace,

Thought Association

Understandable, Moderate Pace,

Thought Association

Can speak normally, with normal voice tone

Relevance And Association

Thought Exhibits

Logical Sequence Make Sense, Has Sense Of Reality

Logical Sequence Make Sense, Has Sense

Of Reality

Talking with sense means she thinking normally

Skin

Assessment Normal Findings Actual Findings InterpretationUniformity Of

Skin ColorUniformity Except In Areas Expose

To The Sun

Uniformity Except In Areas Expose To The

Sun

Uniformity of skin, except areas expose to light and some areas of

lighter pigmentation(conjunctivas, palms, lips, nail beds)

Edema No Presence Of Edema

No Presence Of Edema No water retention

Skin Lesion Freckles, some birthmarks, some

flat and raised nevi;no abraisions

or other lesions

No reckles,some birthmarks,some flat and raised nevi;no abraisions or other

lesions

No lesion noted in the body

Skin Moisture Moisture In Skin Folds & Axillae

Moisture In Skin Folds & Axillae

Some body parts that having sebaceous glands

are moistureSkin

TemperatureUniform, Within Normal Range

Uniform, slightly above normal range

Low grade fever

Skin Turgor Skin Springs Back To Previous State

When Pinched

Skin Springs Back To Previous State When Pinched, except the

part with edema

Skin stays pinched or tented or moves back

slowly

Skull and Face

Assessment Normal Findings Actual findings InterpretationHead Rounded And

Symmetrical, Smooth Skull Contour, No

Nodules

Rounded And Symmetrical, Smooth

Skull Contour, No Nodules

Normal, no signs of any deformities and signs of

skull contour and nodules

Face Light to deep brown,smooth and symmetric facial

movement

Pinkish,smooth and symmetric facial

movement

Fever causes flushing of the skin

Eyes and Vision

Eyebrows Evenly Distributed, Symmetrical, Skin

Intact

Evenly Distributed, Symmetrical, Skin

Intact

Properly distributed, equal

Eyelids Skin Intact, No Discharges, No Discoloration, Symmetrical

Skin Intact, No Discharges, No Discoloration, Symmetrical

Can blink normally

Eyelashes Equally Distributed,

Slightly Curved Outward

Equally Distributed, Slightly Curved

Outward

Turned outward, equally distributed, muscle normally contract

Conjunctiva Shiny, Smooth ,Sometimes Appear Red Or

Pink

Pale conjunctiva Pale, possible anemia

Lacrimal Gland No Edema Or Tearing

No Edema Or Tearing Normal no evidence of any swelling or tenderness

Cornea Transparent, Shiny, Smooth, Blinks

Transparent, Shiny, Smooth, Blinks When

Corneal sensitivity test active,trigeminal nerve is

When Cornea Is Touched

Cornea Is Touched intact,cornea clarity and texture normal.

Pupils Black Color,smooth border,PERRLA

Black Color, smooth border,PERRLA

Pupils are equal,constrict to light dilate in the dark

Eyes(Visual Acuity)

Can see without using eyeglasses

Can’t see without eyeglasses

Nearsightedness, can see only when objects are near

Ears and Hearing

Auricles Color Is Uniform, Symmetric, Mobile, Firm pinna Recoils

When Folded

Color Is Uniform, Symmetric, Mobile, Firm pinna Recoils

When Folded

Color same as facial skin,auricle aligned with outer canthus of the eye.

Response To Normal Voice

Tone

Normal Voice Tone Audible

Cannot hear Normal Voice Tone

Abnormal cannot hear Normal voice, normal

voice tones

Nose and Sinuses

Nares Symmetric, Straight, No

Discharges, Non Swelling, Uniform Color, Not Tender

Symmetric, Straight, No Discharges, Non Swelling, Uniform Color, Not Tender

No presence of lesions,air moves freely as the client

breaths

Lining Of Nose Nasal Septum In Midline

Nasal Septum In Midline

Normal and in midline

Mouth

Lips And Buccal Mucosa

Pink, Soft, Symmetrical,moist

Pink, Soft, Symmetrical,dry

Due to fever which causes dehydration

Teeth And Gums Complete Complete No tooth decay,smooth shiny tooth enamel,no

denturesTongue In Midline, Freely

Movable, PinkIn Midline, Freely

Movable, PinkIn Central

position,moist,slightly rough ;thin whitish

coating,normal,can move freely

Palates And Uvula, Tonsils

Light Pink, No Discharges, Present

Gag Reflex

Light Pink, No Discharges, Present

Gag Reflex

No discoloration, palates are lighter pink hard

palate

Neck and Musculoskeletal SystemShape And Symmetry

Symmetrical Symmetrical Positioned in midline

Spinal Deformities Vertically Aligned Vertically Aligned Normal, no deformities

Inspect Neck Muscles

Symmetrical With Head Centered

Symmetrical With Head Centered

No swelling or masses,coordinated,smoot

h movements with no discomfort

Observe Head Movement

Coordinated, Smooth, Movement

With No Discomfort, Equal

Strength

Coordinated, Smooth, Movement With No Discomfort, Equal

Strength

No discomfort, can hyper extends, laterally flexes

and rotates

Muscle Size Is Symmetrical, No

Contracture, Normally Firm

Size Is Symmetrical, No Contracture, Normally

Firm

Equal strength, symmetrical, normal

Bones No Deformities,No Swelling Or

Tenderness

No Deformities,No Swelling Or

Tenderness

Normal, can move freely, no swelling, deformities or

tenderness

Joints No Swelling, No Tenderness

No Swelling, No Tenderness

Normal, no signs of swelling in area, no

tendernessRange Of Motion Varies To Some

DegreesLimited range of

motionin one or more joints

Can stand and walk, but limited range of motions

due to muscular pain brought by the condition

V. Activities of Daily Living

Functional Health Pattern

Before her present condition

During her present condition

Interpretation

Health Perception and Health Management

Perceives herself as a strong healthy child.

Reports to mother when she

Thinks that she is weak and not healthy

Complies with

The patient had changed her perception about her health because

feels sick

Visits the health center for check-up when sick.

medications of the signs and symptoms brought by the disease

Nutritional and Metabolic

Eats 3 times daily. The usual food intake would be composed of meat vegetables

Drinks 5 glasses of water per day and drinks juice in school

Same amount of food is taken. Avoids eating dark colored food

Drinks 8 glasses of water. Juice is eliminated in her diet

Dark colored food was avoided to easily detect blood in stool

Fluid intake was increased due to replace fluid loss.Juice and other acidic food were eliminated to avoid irritation to gastric mucosa

Elimination Moves bowel once a day without difficulty

Soft firm stoolVoids fair amount of urine without difficulty in normal frequency

Clear, yellow urine

Same bowel movement frequency

Same urine elimination frequency

Same amount and quality of feces and urine

The condition did not affect her elimination pattern

Activity – Exercise Her usual routine was to go to school in the morning and watch television after doing her homework. Also helps in household chores

Doesn’t go to school anymore. Can’t do any household chores. Spends time by talking to her mother and playing games in her mother’s cellphone

Her usual activity was affected because she feels weak due to her condition.

Sleep-Rest Has 8 hours of sleep everyday

Deep, uninterrupted sleep

Gets enough energy from sleepDoesn’t need any sleep aids

Has maximum of7 hours of interrupted sleep

Takes nap in the afternoon to compensate lost sleeping hours

Inadequate sleep due to noisy environment and interrupted sleep due to compliance to the medication

Cognitive-Perceptual

Normal hearing acuity and does not use hearing aid

Uses eyeglasses

Able to comprehend easily

Normal hearing acuity and does not use hearing aid

Uses eyeglasses

Able to comprehend easily

The patient’s condition has no effect on cognition and perception

Self-Perception and Self-Concept Pattern

Perceives herself as a good daughter and student. She shows interest in music.

Feels that she may get lower grades in school because of being absent. She is concerned of not being able to attend her choir rehearsals.

Being confined in the hospital made her unable to go to school and do rehearsals

VI. Development Tasks

Industry vs. Inferiority

At the age of ten, the significant task of the patient is being aware of themselves as

individuals. People at this age work hard at being responsible, being good and doing things right.

Ms. C.T. is starting to recognize her special talents and continue to discover interests as her

education improves. During the assessment, she had verbalized that she is worried of getting

low grades since she can’t listen to class discussion anymore. She also mentioned that there is a

choir competition that she should have attended if she were not in the hospital. It is obvious that

the patient is able to perform her task as a school age child. This will surely help her in building

self-confidence which is important to possess as she grows older.

VII. Laboratory/Diagnostic Findings

CBC and Platelet Count

Norms Result AnalysisHemoglobin 115-155 116 normalHematocrit 0.40-0.48 0.41 normalWBC Count 5.0-10.0 12.8 Due to infectionLymphocyte

s0.2-0.4 0.08 Due to viral infection

Segmenters 0.6-0.7 0.63 normal

Platelets 150-450 110 Due to infection

Torniquet test

10 petichiae per square inch

Interpretation: Positive for Dengue fever syndrome

VIII. Anatomy and Physiology

BLOOD

Blood is a specialized bodily fluid that delivers necessary substances to the body's cells

such as nutrients and oxygen and transports waste products away from those same cells. It is

composed of blood cells suspended in a liquid called blood plasma. Plasma, which comprises

55% of blood fluid, is mostly water (90% by volume), and contains dissolved proteins, glucose,

mineral ions, hormones, carbon dioxide (plasma being the main medium for excretory product

transportation), platelets and blood cells themselves. The blood cells present in blood are mainly

red blood cells (also called RBCs or erythrocytes) and white blood cells, including leukocytes

and platelets. The most abundant cells in vertebrate blood are red blood cells. These contain

hemoglobin, an iron-containing protein, which facilitates transportation of oxygen by reversibly

binding to this respiratory gas and greatly increasing its solubility in blood. In contrast, carbon

dioxide is almost entirely transported extracellularly dissolved in plasma as bicarbonate ion.

Blood is bright-red when its hemoglobin is oxygenated. It is circulated around the body through

blood vessels by the pumping action of the heart.

Blood performs many important functions within the body including: supply of oxygen to

tissues (bound to hemoglobin, which is carried in red cells), supply of nutrients such as glucose,

amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins, removal of

waste such as carbon dioxide, urea, and lactic acid, immunological functions, including

circulation of white blood cells, and detection of foreign material by antibodies, coagulation,

which is one part of the body's self-repair mechanism, messenger functions, including the

transport of hormones and the signaling of tissue damage, regulation of body pH (the normal pH

of blood is in the range of 7.35 - 7.45) (covering only 0.1 pH unit), regulation of core body

temperature

Blood accounts for 7% of the human body weight, with an average density of

approximately 1060 kg/m3, very close to pure water's density of 1000 kg/m3. The average adult

has a blood volume of roughly 5 liters, composed of plasma and several kinds of cells

(occasionally called corpuscles); these formed elements of the blood are erythrocytes (red blood

cells), leukocytes (white blood cells), and thrombocytes (platelets). By volume, the red blood

cells constitute about 45% of whole blood, the plasma constitutes about 54.3%, and white cells

constitute 0.7%. Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its

flow properties are adapted to flow effectively through tiny capillary blood vessels with less

resistance than plasma by itself. In addition, if all human hemoglobin were free in the plasma

rather than being contained in RBCs, the circulatory fluid would be too viscous for the

cardiovascular system to function effectively.

PLATELETS

Platelets, or thrombocytes, are small, irregularly-shaped anuclear cells, 2-4 µm in

diameter, which are derived from fragmentation of precursor megakaryocytes. The average

lifespan of a platelet is between 8 and 12 days. Platelets play a fundamental role in hemostasis

and are a natural source of growth factors. They circulate in the blood of mammals and are

involved in hemostasis, leading to the formation of blood clots. If the number of platelets is too

low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots

can form (thrombosis), which may obstruct blood vessels and result in a stroke and/or a heart

attack. An abnormality or disease of the platelets is called a thrombocytopathy, which could be

either a low number of platelets (thrombocytopenia), a decrease in function (thrombasthenia), or

an increase in the number of (thrombocytosis). There are disorders that reduce the number of

platelets, such as heparin-induced thrombocytopenia (HIT) or thrombotic thrombocytopenic

purpura (TTP) that typically causes thromboses, or clots, instead of bleeding.

A thrombus or blood clot is the final product of blood coagulation, through the

aggregation of platelets and the activation of the humoral coagulation system. Thrombus is

physiologic in cases of injury, but pathologic in case of thrombosis. Some of the conditions in

which blood clots develop include atrial fibrillation (a form of cardiac arrhythmia), heart valve

replacement, a recent heart attack, extended periods of inactivity (see deep venous thrombosis),

and genetic or disease related deficiencies in the blood's clot. Platelet - High and low counts. A

normal platelet count in a healthy person is between 150 and 400 (x 109/L of blood). Both

thrombocytopenia (or thrombopenia) and thrombocytosis may present with coagulation problems

IX. Pathophysiology

Bite of aedesaegypti mosquito carrying a virus

↓

Virus is deposited in the skin then into the circulation

↓

Infects cells and generate cellular response

↓

Initiates destruction of the platelet

↓

Increased potential for hemorrhage

↓

Stimulates intense inflammatory response

Release of exogenous pyrogens body releases anti inflammatory ↓ mediators (histatin,kinins)

  ↑ WBC (Neutrophils & Macrophages) ↓

↓ Vascular response

Release of endogenous pyrogens↓

↓ Redness and heat

Reset of hypothalamic thermostat ↓

↓ Headache, , Epistaxis, Vomiting

Fever Abdominal pain, Circulatory collapse

Muscle contract to Blood vessels constrict ↓

produce more heat to prevent loss of body heat Shock

↓ ↓ ↓

SHIVERING CHILLS DEATH

X. Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

"Limangarawngnilalagnatanganakko," as verbalized by client's mother.

Objective:

Flushed skin

Warm to touch

Restlesness

Vital Signs:

Temp: 38.0 °C

RR: 38 bpm

Hyperthermia related to Infection as evidenced by increased body temperature of 38.0 °C

Short Term Goal:

After 1 hour of nursing intervention, client will maintain normal core temperature of 36.5-37.5.

Independent

Promote surface cooling by means of tepid sponge bath.

Administer replacement fluids and electrolytes.

Maintain bed rest.

Remove excess clothing or blankets.

Provide air condition/fan if appropriate.

Dependent

Administer antipyretics per physician's order.

To decrease temperature by means through evaporation and conduction.

To support circulating volume and tissue perfusion.

To reduce metabolic demands and oxygen consumption.

To facilitate fast recovery.

Short Term Goal:

After 1 hour of nursing intervention, client maintained a core temperature of 36.5 - 37.5.

XI. Drug Study

DRUG NAME CLASSIFICATION ACTION INDICATION CONTRAINDICATION SIDE EFFECTS

NURSING RESPONSIBILITIES

AcetaminophenParacetamol

Brand Name:Tylenol

Analgesic, muscle relaxant, uricosurics

Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not haves anti-inflammatory action because of its minimal effect of peripheral prostaglandin synthesis.

Relief of mild to moderate pain, treatment of fever.

Hypersensitivity: Intolerance to tartrazine, alcohol, table sugar, saccharin.

Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatoxicity, hepatic seizure, renal failure, leucopenia, neutropenia, hemolytic anemia, thrombocytopenia, pancytopenia, rash, urticaria, hypersensitivity, cyanosis, anemia, jaundice, pancytopenia, CNS stimulation, delirium followed by vascular collapse, convulsion, coma and death.

Tell the patient to read the label on other OTC drugs. Advise patient to avoid taking more than one product containing paracetamol (Acetaminophen) at one time; as this may cause toxicity if taken concurrently.

Advise patient to avoid alcohol; acute poisoning with liver damage may result; acute toxicity includes symptoms of nausea, vomiting and abdominal pain. Physician should be notified immediately.

XII. Discharge Planning

MEDICATION

Give acetaminophen in case the temperatures increases.

Give oresol to replace fluid in the body.

EXERCISE

Perform activities of daily living(ADL’s) as tolerated Enough rest

TREATMENT Increased oral fluid intake.

HEALTH TEACHING

D - discuss the possible source of infection of the disease.

E - educate the family/patient on how to eliminate those vectors.

N - never stocked water in a container without cover.

G - gallon, container and tires must have proper way of disposal.

U - use insecticides at home to kill or reduce mosquito.

E - encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito

OPD FOLLOW-UP

Observe carefully for symptoms Give instruction about what symptoms to watch for so she can

alert clinician if additional symptoms occur between visits Follow-up check ups

DIET Encourage nutritious foods like vegetables, meat and fruits.

How does Dengue affect the Body?

Dengue infection is caused by 1 of 4 related, but antigenically distinct, viral serotypes: dengue virus 1 (DENV-1), dengue virus 2 (DENV-2), dengue virus 3 (DENV-3), and dengue virus 4 (DENV-4). Albert Sabin speciated these in 1944. Each serotype is known to have several different genotypes. Dengue viruses are small, spherical, single-stranded enveloped RNA viruses of the family Flaviviridae, genus Flavivirus.

Infection with one dengue serotype confers lifelong homotypic immunity and a very brief period of partial heterotypic immunity, but each individual can eventually be infected by all 4 serotypes. Several serotypes can be in circulation during an epidemic.

Dengue viruses are transmitted by the bite of an infected Aedes mosquito. Globally, aaegypti is the predominant highly efficient mosquito vector for dengue infection, but A albopictus and other Aedes species can also transmit dengue with varying degrees of efficiency.

Aedes mosquito species have adapted well to human habitation, often breeding around dwellings in small amounts of stagnant water found in old tires or other small containers discarded by humans. Female Aedes mosquitoes are daytime feeders. They inflict an innocuous bite and are easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Entire families who develop infection within a 24- to 36-hour period, presumably from the bites of a single infected vector, is not unusual.

Humans serve as the primary reservoir for dengue; however, certain nonhuman primates in Africa and Asia also serve as hosts. Mosquitoes acquire the virus when they feed on a carrier of the virus. The mosquito can transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12 days of viral replication in the mosquito’s salivary glands (extrinsic incubation period). The mosquito remains infected for the remainder of its 15- to 65-day lifespan. Vertical transmission of dengue virus in mosquitoes has been documented. The eggs of Aedes mosquitoes withstand long periods of desiccation, reportedly as long as 1 year, but are killed by temperatures of less than 10°C.

Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 d). Following incubation, a 5- to 7-day acute febrile illness ensues. Recovery is usually complete by 7-10 days. DHF or DSS usually develops around the third to seventh day of illness, approximately at the time of defervescence. The major pathophysiological abnormalities that occur in DHF and DSS are plasma leakage and bleeding. Plasma leakage is caused by increased capillary permeability and may be manifested by hemoconcentration, as well as pleural

effusion and ascites. Bleeding is caused by capillary fragility and thrombocytopenia and may present various ways, ranging from petechial skin hemorrhages to life-threatening gastrointestinal bleeding.

Most patients who develop DHF or DSS have had prior infection with one or more dengue serotypes. In individuals with low levels of neutralizing antibodies, nonneutralizing antibodies to one dengue serotype, when bound by macrophage and monocyte Fc receptors, have been proposed to result in increased viral entry and replication, and increased cytokine production and complement activation. This phenomenon is called antibody-dependent enhancement. In addition, certain dengue strains, particularly those of DEN-2, have been proposed to be more virulent, in part because more epidemics of DHF have been associated with DEN-2 than with the other serotypes.

Classification of Dengue Hemorrhagic Fever

Grade I

There is fever accompanied by non-specific constitutional symptoms and the only hemorrhagic manifestation is positive tourniquet test

Grade II

All signs of Grade I plus bleeding from the nose,gums, GIT are present.

Grade III

There is presence of circulatory failure as manifested by weak pulse, narrow pulse pressure, hypotension, cold clammy skin and restlessness

Grade IV

There is profound shock, undetectable blood pressure, and pulse.

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