2Presenting Symptoms ( Admit 20/5/08 8pm ) V.S / Indian / Female / 39 yearsFever x 4/7a/w chills but no rigorsDiarrhoea and vomiting x 2 daysNo bleeding tendencyNo SOBNo chest painLMP : 16/5/08 ( currently day 4 menstruation )Not staying at dengue area ( No recent fogging )No history of recent travelNo family members with similar problem
3Social HistoryWorking in Taman University ( dengue area ) in a textile factoryRecently engagedCurrently lives with family
7What phase of Dengue illness is the patient in now? Insert graph
8Investigations taken FBC BUSE/ Creatinine/ LFT Dengue Serology BFMP x 3CXRStoolOva and cyst, C & S
9Plan of management Hourly vital signs monitoring until stable Notify as Dengue Haemorrhagic FeverRun 2 pint NS fastMaintenance IVD 8 pints Normal Saline over 24 HIV Maxolon 10 mg tdsT. Ranitidine 150 mg bd4 hourly FBCTDS MO review
10Comment on the management ? Does the patient fulfill the criteria for DHF ?
11Comment on these orders ‘T. Ranitidine 150 mg bd’‘4 hourly FBC’‘TDS MO review’
12Next review - 13 hours defervescence– Day 5 fever onset ( 21/5/08 , 9am ) Vomit x 1 , Epigastric painNo diarrhoea or hematuriaBP : 107/70 mmHg PR : 81 sPO2 100% ↓Room AirLungs : clearOrder ( by doctors )Trace FBC taken at 7.00AMT Omeprazole 40mg OD ( off T Ranitidine )Watch out for bleeding tendencyCont IVD 8 pint Normal Saline over 24 hoursTransfer to Dengue Ward after review resultCalculate hours of defervescence
13Monitoring in dengueComment on the review frequency
14What are the signs of deterioration that were not appreciated by the doctor?
18What will be correct diagnosis of the current patient condition? DATE / TIME20/521/57PM7AM5PMHCT39.939.335.5HB14.413.611.8PLT151913WCC126.96.36.199
1936 hours defervescence( 22/5/08, 8am ) – Day 6 fever onset Still abdominal pain T : 38oCBP 130/60 mmHg PR 92/minAbdomen – distended and tender but softLungs – clearMild pedal oedemaOrder by doctorPR to look for malena↓IVD to 6 pints/24 hoursRefer HDU/ICU care
20What do you think is happening? What will be the appropriate management at this stage?
2148 hours post defervescence ( 22/5/08, 1pm ) – Day 6 fever onset Noted lungs creptsPeriorbital swellingBilateral leg and arm oedemaOrder by doctorDIVC screenGXM 2 pint pack cellsOff IVDIV frusemide 40mg statIV antibiotics – Ceftriaxone after blood cultureUltrasound abdomen urgentGroup screen and hold required for all DHF grade3&4
26Day 3 at 57 hours post admission ( 23/5/08, 5am ) – Day 7 fever onset Staff nurse noted patient become more unwellDoctor ( on call ) reviewSeptic looking E4M4V4BP 149/72mmHg PR 84/min ( good volume )Lungs clear CRT < 2 secOrderPut back IVD 5 pint over 24 hoursContinue antibioticHourly vital sign monitoringABG stat – compensated severe metabolic acidosis pH HCO3 8 BE -14
27Ultrasound report U/S Abd done 22/5/08 4.30 p.m. Normal liver echotextureAscites with minimal bilateral perinephric fluid ?causeThickened gallbladder wall may represent acute cholecystitis or due to presence of ascitesEvidence of liver abscess not seenHypoechoic lesion posterior wall of uterus, possibly a fibroid
28D3 admission (23/5/08, 8am )- at 60 hours post defervescence Abdominal pain persistentClinically :Septic looking; T : 37.4oC E4V2M5BP : 140/89 mmHg PR : 92/minWarm peripheries , CRT < 2 secSpo2 100% , N/prong oxygen 10L/minLungs- rhonchi with ↓ air entry left basalAbdomen – soft, distendedBilateral pedal oedema
29Investigation results ABG – worsening compensated metabolic acidosis pH 7.36 HCO314 BE -9 pCO2 27Dengue serology : Ig M/G – Non reactiveManagement :IV frusemide 40mg statTransfer to HDUIVD 1 pint over 24 hoursIV NaHCO3 50cc slow bolusRepeat dengue serology
30Further management at D3 admission (23/5/08, 11.15am ) at HDU Planned for 1 pint PC and 2 units FFP transfusionIVD 4 pints Normal Saline / 24 HIntubated for Type 1 respiratory failure at 65 hours of admission ( 1pm )CXR – bilateral pleural effusion
31Further management at D3 admission (23/5/08) at ICU ( 69 hours post admission ) Septic workup – then IV Tazocin 2.25g QID for ? Acute cholecystitis ( ultrasound findings ) / Nosocomial infectionIV Gelafundin bolus 250ccIV Frusemide 40mg statReferred to surgical team – conservative management for ? Acute cholecystitis
33Further management IV frusemide 80 mg stat Reduce IVD 42 ml/hour + oral feeding 40ml/hour – 2litre /dayStarted CVVHDFGiven DIVCx2 regime with Whole blood 6 pints of blood in total – first pint whole blood given at am, 24/5/08 ( 87 hours post admission )Started on inotropic support – Dopamine with added on NoradrenalineNeeding increase ventilatory support , BP ↓ and developed AF
34Further management Started IV amiodarone Bleeding tendency – oozing from femoral siteHypothermicBP dropping despite inotropic support.Patient succumb to her illness at 112 hours post admissionLiver biopsy tissue sample sent for :Dengue PCR Dengue Type 1 detected
35Results Dengue Serology (21/5/08) –day 4 illness Ig G : Non – reactiveIg M : Non – reactiveDengue Serology (26/5/08) – day 9 illnessIg G : ReactiveBlood C&S (22/5/08) No sampleBlood C&S (23/5/08) No growth