Day-Five Fever at a Sub-Centre: Spotting the Critical Phase
A 45-year-old farm labourer comes to a sub-centre at 4 p.m. on the fifth day of fever. He says the fever was 39°C for three days, but today it is only 37.8°C, and he is relieved. He has vomited twice since morning, complains of pain behind the eyes and a dull upper abdominal pain, and has drunk only half a glass of water because of nausea. He looks restless, and his hands and feet feel cold and clammy. Lying down, BP is 92/60 mmHg and pulse 108 per minute and thin; when he sits up, BP falls to 82/54 mmHg and pulse rises to 120. Capillary refill is 4 seconds, respiratory rate 24 per minute, and the urine he passed in the morning was small in amount and dark. No rash is seen, but the tourniquet test is positive. The laboratory is closed, so no platelet count or haematocrit is available today. His brother-in-law, waiting outside, says the fever has gone and they should take him home and return only if the fever comes back.
1. List the findings that worry you, and explain why a fall in temperature on day 5 is not good news in this illness.
Read the worked answer
Findings that worry me:
- Persistent vomiting and upper abdominal pain.
- Cold, clammy hands and feet with a capillary refill of 4 seconds (normal under 3).
- Postural fall in systolic BP (92 to 82 mmHg) with a pulse rise of 12 per minute on sitting.
- Pulse 108–120, thin, with a pulse pressure of only 32 mmHg.
- Restlessness, thirst and reduced fluid intake.
- Scanty, dark urine - a sign of poor perfusion or dehydration.
- Positive tourniquet test, pain behind the eyes.
Why day 5 matters: in dengue the illness usually passes through a febrile phase of 2–7 days and then a critical phase of about 24–48 hours, often as the temperature settles. At that point plasma leakage begins, so the fever falling is not recovery - it is exactly the window in which shock appears. A patient who is discharged because "the fever has gone" can return in shock.
Judgement: this man has warning signs and early compensated shock; he cannot be sent home.
2. What will you do at the sub-centre in the next hour, within the scope of a vocational health care worker?
Read the worked answer
Sequence:
- Inform the Medical Officer immediately - this is a referral decision above my level, and the MO must examine him.
- Position: lay him flat with legs slightly raised; do not let him sit or stand repeatedly for BP checks.
- Keep him warm, loosen tight clothing, and reassure him and the family.
- Fluids: if conscious and not vomiting continuously, give ORS in small sips by spoon, frequently. Record how much is taken and how much is vomited.
- Monitor and chart BP, pulse, respiratory rate, temperature, capillary refill and urine output every 15 minutes on a slip with the time written against each reading.
- Avoid harmful measures: no aspirin, ibuprofen or other NSAIDs; no intramuscular injections, which cause bleeding in a low-platelet patient; no unnecessary IV attempts at a centre without facilities.
- Arrange referral to a facility with inpatient beds and IV fluid capability, using 108 or the block vehicle, and send the observation chart with him.
Reasoning: a trend chart is more useful to the receiving doctor than a single reading, and each of the above steps is within a trained assistant's role without overstepping into prescribing.
3. Explain to the brother-in-law, in plain words, why the patient must not go home, why no painkiller from the shop should be given, and what to watch during transport.
Read the worked answer
Explaining the danger: "His fever has come down, but that is the time in this illness when water can leak out of the blood vessels. His hands are cold, his pulse is fast and his BP drops when he sits. That is the body struggling. At home there is no way to watch him every 15 minutes, and he can get worse within an hour."
Why no painkiller: "Tablets like aspirin, ibuprofen or a combination painkiller thin the blood and can cause bleeding from the stomach in this illness. Paracetamol alone, only in the dose the doctor says, is what is allowed."
During transport:
- Keep him lying down, not sitting upright.
- Keep giving small sips of ORS if he is awake and not vomiting.
- Watch for bleeding gums, black stools, vomiting blood, very cold skin, or drowsiness - tell the driver to hurry if any appear.
- Carry the observation chart and the referral slip.
Reasoning: families cooperate when the reason is explained in their own terms, and a relative who knows what to look for becomes a second observer during a 30-minute journey.