1. D NGUE WORKSHOP 2015 ID HSB 2015

2. OPD – CASE 5 ID HSB 2015

3. History 49 years old lady DM,HPT Lithotripsy done 2 years ago, on urology follow up Complained of fever for 5 days Seen GP D1 of fever – symptomatic treatment ID HSB 2015

4. Day 5 of illness, came to KK Registered 10.30 am Complaining of fever T 38°C, vital signs stable As such, patient was waiting for her turn to see Doctor ID HSB 2015

6. Fever Clerking Sheet ID HSB 2015

7. History Seen by MO at 11.45 am Fever 5 days with myalgia and arthralgia Left loin pain Nausea Vomiting > 10x yesterday, today 2x Poor oral intake No diarrhea, giddiness or shortness of breath ID HSB 2015

8. Examination BP 120/80mmHg, PR 84/min T 38 C Tender at left lumbar area. ID HSB 2015

9. What is your diagnosis? Dengue fever with warning signs Acute pyelonephritis UTI with renal calculi Diabetic ketoacidosis Food poisoning Fever, myalgia and arthralgia Must think of Dengue Fever ID HSB 2015

10. Investigations FBC Renal Profile UFEME – Leucocytes and nitrate negative – Protein 2+ Blood large, urine ketone : negative Reflomet stat : 16.5mml/L ID HSB 2015

11. Problem list : DM/HPT History of renal stone High DXT Fever, myalgia, arthralgia Loin pain Persistent vomiting ID HSB 2015

12. What would you do now Send patient to emergency room Option A IVD 1 pint NS, PCM, IV maxolon, IV zantac –w–wait for investigation results Option B ( weight 70kg) Trace FBC urgently (in view of warning signs ) –S–Start fluid resuscitation 5/3/2 while waiting for results OR ID HSB 2015

13. Vital signs 1 hour later (1.10 pm) –B–BP 109/80 PR 70 T 37C –1–1 pint NS in progress FBC: Hb 17.3 wbc 5.4 HCT 50.8 Platelet 3 Dengue NS1 : Positive Diagnosis : Dengue fever, Day 5 illness, febrile phase with warning signs. Uncontrolled DM TRO Renal colic

14. Patient’s medical history Was the patient on Betablocker ? What was the patient’s baseline BP/PR Patient’s baseline HR may be lower if he is taking Betablocker. For instance, in a patient with baseline HR 60/min, HR >80/min may already considered as “ relative tachycardia” Medications : T. Metformin 500mg BD T. Gliclazide 80mg BD T. Atenolol 50mg OD T. Perindopril 4mg OD T. Aspirin 150mg OD ID HSB 2015

15. CRITERIA FOR HOSPITAL REFERRAL / ADMISSION Symptoms: 1. Warning signs 2. Bleeding manifestations 3. Inability to tolerate oral fluids 4. Reduced urine output 5. Seizure Signs: 1. Dehydration 2. Shock 3. Bleeding 4. Any organ failure ID HSB 2015

16. CONSIDER EARLY ADMISSION ID HSB 2015 Co-morbidity e.g. DM, HPT, IHD, Coagulopathies, Morbid Obesity, Renal failure, Chronic Liver disease, COPD Elderly > 65 Pregnancy Social factors: living far, living alone etc Lab. criteria Rising HCT with reducing platelet count

17. Consulted FMS : refer patient to the nearest hospital for admission. Notify Dengue IVD : Fluid regime for warning signs ( 5/3/2) Hourly BP/PR : close monitoring ID HSB 2015

18. PREREQUISITES FOR TRANSFER All efforts must be made to optimise the patient’s condition before and during transfer. The Emergency Department and Medical Department of the receiving hospital must be informed prior to transfer. Adequate and essential information must be sent together with the patients, it includes fluid chart, monitoring chart, dengue clerking sheet. ID HSB 2015

19. THANK YOU ID HSB 2015