To follow these patients closely:

• Ask the history of bleeding (admit and give blood transfusion if there is a significant amount of blood loss, ~10% of total blood volume).
  
• Do physical examination:
  - Vital signs - sings of shock: rapid and weak pulse, narrowing of pulse pressure, hypotension - if present, give IV fluid immediatedly and asmit.
  - Palpate the liver - liver enlargement and tenderness indicate nearness to or entering the critical phase; observe closely or admit.
  - Repeat tourniquet test if it was negative.
  
• Do CBC and follow CBC everyday:
  - Leukopenia < 5,000 cells/cu.mm. and lymphocytosis, increase in atypical lymphocyte indicates that within the next 24 hours, the patient will have no fever(7) and will enter critical phase if they are DHF cases.
  - Thrombocytopenia < 100,000 cells/cu.mm. indicates that the patient is entering a critical phase and needs close observation in the hospital.
  - Rising Hct 10 - 20% indicates that the patient is in the critical period and needs IV fluid therapy if he cannot have good oral intake. Adit this patient and give isotonic salt solution.
  

(e) Advise caretakers about warning signs of shock so that parents should bring their children to the hospital as soon as possible.

• Clinical deterioration when defervescence occurs.
  
• Bleeding
  
• Acute, severe abdominal pain/vomiting.
  
• Very drowsy, patient looks weak and sleeps all the time.
  
• Refuses to eat or drink (some may complain of being very thirsty).
  
• Restless, irritable.
  
• Change in behaviour.
  
• Cold, clammy or mottling skin.
  
• Not passed urine for 4 - 6 hours.
  

(f) Indications for admission

• Very weak and cannot have adequate oral intake.
  
• Bleeding.
  
• Platelet < 100,000 cells/cu.mm. and/or rising Hct 10 - 20%.
  
• Clinical deterioration when defervescence occurs.
  
• Acute, severe abdominal pain/vomiting.
  
• Shock/impending shock.
  
• Rapid pulse and no fever.
  
• Capillary refill >2 seconds.
  
• Cold, clammy skin, mottling, restless.
  
• Pulse pressure < 20 mm.Hg., e.g. 100/80, 90/70,
  
• Hypotention.
  
• No urine for 4 - 6 hours.
  
• Change of consciousness, stuporous or aggressive behaviour which may indicate more severe disease, encephalopathy.
  
• Parental anxiety, live far away from the hospital.