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1 Case Presentation 1 Chua Hock Hin, HSAJB Suresh Kumar, HSB.

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Presentation on theme: "1 Case Presentation 1 Chua Hock Hin, HSAJB Suresh Kumar, HSB."— Presentation transcript:

1 1 Case Presentation 1 Chua Hock Hin, HSAJB Suresh Kumar, HSB

2 2 Presenting Symptoms ( Admit 20/5/08 8pm )  V.S / Indian / Female / 39 years Fever x 4/7 – a/w chills but no rigors Diarrhoea and vomiting x 2 days No bleeding tendency No SOB No chest pain LMP : 16/5/08 ( currently day 4 menstruation ) Not staying at dengue area ( No recent fogging ) No history of recent travel No family members with similar problem

3 3 Social History  Working in Taman University ( dengue area ) in a textile factory  Recently engaged  Currently lives with family

4 4 Physical Examination Conscious, alert GCS full BP : 126/75 PR : 58 (good volume) T : 37 GM : 6.9 CRT < 2 sec Clinically pink, no jaundice Dehydrated CVS : DRNM Lungs : Clear, A/E equal Abd : Soft, non- tender No rashes/ bruises seen No lymphadenopathy Estimated body Wt - 50kg

5 5 Diagnosis  Dengue Fever  Differential : Acute gastroenteritis  FBC from A&E :  Hemoglobin 144 G/L  Hematocrit 39.9  Platelet 15 G/L  WCC 2.2

6 6  What is the diagnosis?

7 7  What phase of Dengue illness is the patient in now?

8 8 Investigations taken – FBC – BUSE/ Creatinine/ LFT – Dengue Serology – BFMP x 3 – CXR – Stool Ova and cyst, C & S

9 9 Plan of management Hourly vital signs monitoring until stable Notify as Dengue Haemorrhagic Fever Run 2 pint NS fast Maintenance IVD 8 pints Normal Saline over 24 H IV Maxolon 10 mg tds T. Ranitidine 150 mg bd 4 hourly FBC TDS MO review

10 10 Comment on the management ?  Does the patient fulfill the criteria for DHF ?

11 11 Comment on these orders ‘T. Ranitidine 150 mg bd’ ‘4 hourly FBC’ ‘TDS MO review’

12 12 Next review - 13 hours defervescence– Day 5 fever onset ( 21/5/08, 9am )  Vomit x 1, Epigastric pain  No diarrhoea or hematuria  BP : 107/70 mmHg PR : 81 sPO2 100% ↓ Room Air  Lungs : clear  Order ( by doctors )  Trace FBC taken at 7.00AM  T Omeprazole 40mg OD ( off T Ranitidine )  Watch out for bleeding tendency  Cont IVD 8 pint Normal Saline over 24 hours  Transfer to Dengue Ward after review result

13 13 Monitoring in dengue  Comment on the review frequency

14 14  What are the signs of deterioration that were not appreciated by the doctor?

15 15 18 hours defervescence(21/5/08, 2pm ) Not transferred to Dengue Ward yet Blood Investigations taken at 7.00AM reviewed : – ALT : 407 / AST : 1230 – CK : 359 / LDH : 1912 – WCC : 2.10 Hb : 13.6 Hct : 39.3 Plt : 19.4 – Cr: 70 / Urea :3 / K :2.85 – PT:15 / PTT:76.6 / INR : 1.3 CXR : Clear lung fields

16 16 25 hours defervescence(21/5/08, 9pm) Reviewed by doctor on call : Comfortable ????? sPO2 99% ( room air ) BP : 116/52mmHg PR : 104 /min T : 37.7 o C ABG : pH 7.43 pCO2 44 PO2 153 HCO3 28 BE 4 Order – Continue ward management

17 17  Comment on the use of ABG at this stage

18 18  What will be correct diagnosis of the current patient condition? DATE / TIME 20/521/5 7PM7AM5PM HCT HB PLT WCC

19 19 36 hours defervescence( 22/5/08, 8am ) – Day 6 fever onset  Still abdominal pain T : 38 o C  BP 130/60 mmHg PR 92/min  Abdomen – distended and tender but soft  Lungs – clear  Mild pedal oedema  Order by doctor  PR to look for malena  ↓ IVD to 6 pints/24 hours  Refer HDU/ICU care

20 20  What do you think is happening?  What will be the appropriate management at this stage?

21 21 48 hours post defervescence ( 22/5/08, 1pm ) – Day 6 fever onset  Noted lungs crepts  Periorbital swelling  Bilateral leg and arm oedema  Order by doctor  DIVC screen  GXM 2 pint pack cells  Off IVD  IV frusemide 40mg stat  IV antibiotics – Ceftriaxone after blood culture  Ultrasound abdomen urgent

22 22 DATE / TIME 20/521/522/5 7PM7AM5PM12AM7AM12PM HCT HB PLT WCC

23 23  Comment on the usage of frusemide at this stage

24 24 Date20/521/522/5 T. Bil ALT AST * CK359-- LDH Creat PTT INR

25 25  What else is happening

26 26 Day 3 at 57 hours post admission ( 23/5/08, 5am ) – Day 7 fever onset  Staff nurse noted patient become more unwell  Doctor ( on call ) review  Septic looking E4M4V4  BP 149/72mmHg PR 84/min ( good volume )  Lungs clear CRT < 2 sec  Order  Put back IVD 5 pint over 24 hours  Continue antibiotic  Hourly vital sign monitoring  ABG stat – compensated severe metabolic acidosis pH 7.38 HCO3 8 BE -14

27 27 Ultrasound report U/S Abd done 22/5/ p.m. – Normal liver echotexture – Ascites with minimal bilateral perinephric fluid ?cause – Thickened gallbladder wall may represent acute cholecystitis or due to presence of ascites – Evidence of liver abscess not seen – Hypoechoic lesion posterior wall of uterus, possibly a fibroid

28 28 D3 admission (23/5/08, 8am )- at 60 hours post defervescence Abdominal pain persistent Clinically : Septic looking; T : 37.4 o C E4V2M5 BP : 140/89 mmHg PR : 92/min Warm peripheries, CRT < 2 sec Spo2 100%, N/prong oxygen 10L/min Lungs- rhonchi with ↓ air entry left basal Abdomen – soft, distended Bilateral pedal oedema

29 29 Investigation results  ABG – worsening compensated metabolic acidosis pH 7.36 HCO 3 14 BE -9 pCO 2 27  Dengue serology : Ig M/G – Non reactive  Management :  IV frusemide 40mg stat  Transfer to HDU  IVD 1 pint over 24 hours  IV NaHCO3 50cc slow bolus  Repeat dengue serology

30 30 Further management at D3 admission (23/5/08, 11.15am ) at HDU  Planned for 1 pint PC and 2 units FFP transfusion  IVD 4 pints Normal Saline / 24 H  Intubated for Type 1 respiratory failure at 65 hours of admission ( 1pm )  CXR – bilateral pleural effusion

31 31 Further 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 infection  IV Gelafundin bolus 250cc  IV Frusemide 40mg stat  Referred to surgical team – conservative management for ? Acute cholecystitis

32 32 D4 admission (24/5/08) – 85 hours post admission  Day 8 Illness  GC worsened  BP : 135/83 mmHg, PR : 131/min  Not on inotropic support  ABG : Compensated metabolic acidosis  Hb reducing trend (Hb : 14  10.6  7.4)  Abdomen more distended  Urine output ↓↓  Anuric  PT/PTT/INR : 32.5 / 65.8 / 3.44

33 33 Further management  IV frusemide 80 mg stat  Reduce IVD 42 ml/hour + oral feeding 40ml/hour – 2litre /day  Started CVVHDF  Given DIVCx2 regime with Whole blood 6 pints of blood in total – first pint whole blood given at 11.30am, 24/5/08 ( 87 hours post admission )  Started on inotropic support – Dopamine with added on Noradrenaline  Needing increase ventilatory support, BP ↓ and developed AF

34 34 Further management  Started IV amiodarone  Bleeding tendency – oozing from femoral site  Hypothermic  BP dropping despite inotropic support.  Patient succumb to her illness at 112 hours post admission  Liver biopsy tissue sample sent for :  Dengue PCR  Dengue Type 1 detected

35 35 Results  Dengue Serology (21/5/08) –day 4 illness  Ig G : Non – reactive  Ig M : Non – reactive  Dengue Serology (26/5/08) – day 9 illness  Ig G : Reactive  Ig M : Non – reactive  Blood C&S (22/5/08)  No sample  Blood C&S (23/5/08)  No growth


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