1. Facilitators: Dato Dr. Sree Raman Dr. Lim Chew Har Dr. Ho Bee Kiau
Case Management 2
Facilitators:
Dato Dr. Sree Raman
Dr. Lim Chew Har
Dr. Ho Bee Kiau

2. 26/6/08 Klinik Kesihatan FEMALE 60 year old
C/O: Fever for 3 days
Dizzy and lethargy
Joint pain and myalgia
Nausea but no vomiting
PMH: DM and HPT. Not on treatment
O/E:
T=38 C
BP=120/70

3. Cont.. Fever ? Cause Treatment: Paracetamol Cefaclor 375mg bd
Q1: What is your comment on the case
management?

4. Answer Q1:
Page 16
A Stepwise approach on outpatient management of dengue infection is important
Step 1: Overall assessment
1. History
2. Physical examination
3. Investigations
Step 2 : Diagnosis, disease staging and severity assessment
Step 3 : Plan of management

5. 27/6/08 (Day 4 of fever) Klinik Kesihatan
Patient came back to KK the next day, still c/o fever with diarrhea, vomiting and epigastric pain, feeling lethargy.
Seen by MA, O/E T=38.5 C, BP 110/65, PR 100/min, hydration fair, PA: soft, mild epigastric tenderness.
Diagnosis: AGE with gastritis TRO DF
FBC: Hb 10.3, Platelet count 120 (HCT 41.5%)
TCA cm to repeat FBC
Q2: a) What are the warning signs?
b) Would you have admitted this patient?

6. Answer Q2(a): WARNING SIGNS Warning signs Abdominal pain or tenderness
Page 17
WARNING SIGNS
Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (pleural effusion, ascites)
• Mucosal bleed
• Restlessness or lethargy
• Liver enlargement > 2 cm
• Laboratory : Increase in HCT concurrent with rapid
decrease in platelet

7. Answer Q2(b): CRITERIA FOR HOSPITAL REFERRAL / ADMISSION
Page 18
The decision for referral and admission should depend on
the Total Assessment:
1. Symptoms :
• Warning signs
• Bleeding manifestations
• Inability to tolerate oral fluids
• Reduced urine output
• Seizure
2. Signs :
• Dehydration
• Shock
• Bleeding
• Any organ failure

8. 3. Special Situations :
• Patients with co-morbidity e.g. diabetes, hypertension,
ischaemic heart disease, coagulopathies, morbid obesity,
renal failure, chronic liver disease, COPD, haemoglobinopathy
• Elderly (<65 years old)
• Pregnancy
• Social factors that limit follow-up e.g. living far from health
facility, no transport, patient living alone
4. Laboratory Criteria:
Rising HCT accompanied by reducing platelet count

9. 28/6/08 (Day 5,10:00 am- Saturday)
Ambulance call. Brought to KK at 12:05pm
Seen by MA
H/o:
Fever 5 days, still has diarrhea and vomiting
Headache and joint pain
Epigastric pain for 2 day
Dark sticky stool 2/7
O/E:
BP unrecordable. Alert conscious
Pulse: fast and small volume

10. Treatment: IVD- Hartman’s 3pint via 2 IV lines
DIAGNOSIS : UPPER GIT BLEED WITH SHOCK SECONDARY TO DHF OR PEPTIC ULCER
Ix: RBS=21.4mmol/L
Treatment: IVD- Hartman’s 3pint via 2 IV lines
Wrote a referral letter
Referred to hospital and accompanied by JM
Q3. What could have been done by the
health provider at KK?

11. Answer Q3: The BP, Pulse monitoring must be continued while in
Page 18
The BP, Pulse monitoring must be continued while in
the ambulance and patient must be accompanied by MO/MA

12. At 12:35pm, the patient was transferred to Hospital A (as requested by the family because one of their family member worked at Hospital A and she was on follow up for DM there)
Arrived at Hospital A at 12:55pm
JM went to the casualty and showed referral letter to the counter staff at casualty. Case was not accepted because no bed available
Case was sent to General Hospital

13. (Day 5,1.30PM – 2 hours defervescence):
A+E General Hospital
(Day 5,1.30PM – 2 hours defervescence):
C/O:
- Fever x 5/7. Settled today
- Diarrhoea (5x/day) & black tarry stool for 2 days
- Vomiting with epigastric pain
- Giddiness, lethargic, myalgia
- No hematemesis
Neighbour admitted for dengue, still in ward
PMH: Diabetes Mellitus and Hypertension
DH: Metaprolol 50mg bd and ramipril
Glicazide 80mg bd and simvastatin 20mg
Took NSAIDS for shoulder pain & myalgia

14. Q4. What is your diagnosis?
Examination:
Wt 55kg
Pink, alert and conscious
BP:90/68mmHg PR:65/min T:37’C
SPO2:98-100% Cold peripheries. No rash
Capillary refill time > 2sec
CVS: S1S2 ESM at left sternal edge
Lungs : clear
Abdomen: soft, mild epigastric tenderness
PR: malena
Glucometer :14.9mmol/l
Q4. What is your diagnosis?

15. Answer Q4: Dengue Shock syndrome ( Grade 3) with upper GI bleed.
Underlying uncontrolled DM

16. Q5. Comment on the management
Diagnosis :
1) Hypotension secondary to AGE
2) Uncontrolled DM
3) UGIT bleed
Management:
- Admit general ward
- Given 1pint Hartman fast
Investigations:
FBC, BUSE , RBS, Stool C&S
Q5. Comment on the management

17. Answers Q5
Plan for fluid therapy should be documented
This patient should be admitted to HDW or ICU for close monitoring and management

18. Day 5 (1630) ( 4 hours defervescence )
BP:94/73mmHg PR:101/min
T:37’C SPO2 97%
G/M:17.9mmol/l
CVS: DRNM
Lungs :clear
Abdomen: soft,non tender
PR: yellowish stool,
no malena
Twbc:4.6 x109
Hb:15.4g/dl HCT:46.5
Plt:4 x109
Urea 13mmol/l Na 125 K 4.1
INR APTT 59
ECG: Normal

19. Diagnosis:
1) Fever with severe thrombocytopenia
Dengue haemorrhagic fever Grade III (CriticalPhase)
2) DM uncontrolled
Mx:
- Start iv dopamine 150mg in 50cc run 5cc/h
- SC Actrapid 10 u tds
- IV fluid 6 pint N/S over 24 h
- to transfuse 4 u platelet
- monitor I/O

20. Q6.
Explain why Hb and HCT in this patient
was not as low as expected.
Comment on the use of dopamine at this stage.

21. Answers Q6
Hb and HCT were relatively high (inappropriate) considering patient had GIT bleed.
Her high HCT was due to hemoconcentration as a result of plasma leakage during this critical phase.
It was expected that Hb and HCT would drop once IV fluid therapy being given and hemoconcentration improved.
The use of inotropic/vasopressor support at this stage
( when the patient is still hypovolaemic) may further worsen the tissue hypoxia, due to vasoconstriction effect of the dopamine.

22. Q7: Do you agree with the fluid
therapy and platelet transfusion?

23. Answers Q7
The IV fluid regime was inadequate. IV fluid therapy should be initiated with resuscitation regime as patient was in shock.
Resuscitation rate : 10-20ml/kg fast with crystalloid for the first 2 cycles then colloid if hemodynamically not improved.
Meanwhile packed cell should be made available as patient was bleeding. Other blood products such as platelet and FFP may be given

24. Day 5 (2130) ( 9 hours defervescence)
BP:102/68mmHg PR:101/min T:37’C RR 24/min SPO2 95% O2 2l/min Lung: crepitation bibasal Abdo: Soft Urine output: 10ml/hr Diagnosis - DSS - Uncontrolled DM - Acute renal failure - Fluid overload
- WCC 7 Hb 16.5 Hct 49 Platelet 16,000 -BUSE:13.6/135/6.8/ /134/7.0/105 -Amylase:69 -ABG: ph:7.3 HCO3:11.7 PCO2:23.7 PO2: Chest X ray: pleural effusion on R side

25. Q8 : What would you do now?

26. Answers Q8 Fluid resuscitation was inadequate as evidenced by
persistently raised HCT and severe metabolic acidosis.
The patient had ongoing plasma leakage with pleural
effusion and further fluid resuscitation would most likely
lead to worsening of respiratory function so intubation was
indicated.
The patient should have been referred to intensive care unit
for consideration of ICU admission.

27. Early recognition and treatment of shock is essential
Management of DSS is a medical emergency and
requires prompt and adequate fluid replacement
Early and effective replacement of plasma losses
results in a favorable outcome, so consider early referral
to ICU
Severe metabolic acidosis is a sign of prolonged shock
and tissue hypoxia
In general, respiratory support should be considered early
in a patient’s course of illness and should not be delayed
until the need arises.

28. Treatment: IV lasix 40mg stat IV cocktail stat & 50ml NaHCO3 Reduce IV drip to 4pints/24 hours Insulin infusion 3u/hr CVP attempted x 2 but failed

29. Q9 : Would you have attempted central line
insertion ?

30. Volume resuscitation does not require a central venous
Answer Q9
Volume resuscitation does not require a central venous
catherisation (CVC) if sufficient peripheral intravenous
access can be obtained.
When CVC is indicated it should be inserted by a
skilled operator, preferably under ultrasound guidance
if available.
Subclavian vein cannulation should be avoided as far
as possible.

31. Day 6 (0810am) ( 20 hours defervescence)
On dopamine 4cc/h. Tailing down dose
Examination:
Alert GCS 15/15 RR 22/min,pink,no jaundice
BP:178/83mmHg PR:110/min T:37’C
Lungs: crepitation at the bases
Abdomen: tenderness at the epigastrium
Bleeding at venepuncture
Urine output –anuric since 12 midnight
Ix:
ABG:PH: HCO3: PO2:98
BUSE:17.7/134/.6.9/106

32. RESULTS: Date/result 28/6 (Day5) 1520 28/6 20.30 29/6 (Day 6) 0400
1000
TWBC
4.6
7.7
13.7
12.7 HB
15.4
16.5
12.3
11.2
HCT
46.5
48.3
37.6 33
PLT 4 16 15 17
BUSE
13.6/135/6.8/104
16.2/134/7.0/105
16.9/136/5.6/104

33. Diagnosis:
1) Dengue shock syndrome with sepsis
2) Acute renal failure secondary to (1)
3) Persistent hyperkalaemia-cocktail x 2
4) Thrombocytopenia
6) Uncontrolled DM

34. Mx:
- Add Fortum 1g od
- Iv Azithromycin 500 mg od
- IV fluid 1pint/24 hours
- Increase insulin to 4 u /h -1H g/m (aim 6-8mmol/l)
- iv sodium bicarbonate 50cc over ½ h
- iv cocktail stat kiv hyperkalaemia –for dialysis
- iv ranitidine 50mg tds
- Put on HFMO2 10L/min

35. 1030am ( 22 hours defervescence) :
BP dropping to 98/28mmHg
Mx:
Started on iv noradrenalin 8 mg in 50cc D5% run at 2cc/h
12 noon ( 24 hours defeversence)
Reviewed ABG:PH : HCO3:7.5
CBD: urine 10cc only
Patient :acidotic breathing
Case noted to specialist:
- to transfused platelet 4 u than proceed with peritoneal dialysis
- refer anaest

36. Patient then desaturated
o/e:
- Tachypnoeic,gasping
- Emergency intubation
- BP recordable after started on tripple inotropic agent:81/53mmHg
pulse rate:154/min-weak
cold peripheries
- Pupil dilated and non reactive

37. Pt asystole then
CPR done-3 ampoules of atropine and adrenalin given but not reverted.
Confirmed death:2.30pm ( 26 hours defervescence)
Cause of death:septicaemic shock

38. Result / date
28/6
29/6
PT/ APTT
INR:2.48
Ratio:3.84
ABG
pH:7.31
HCO3:11.7
PO2:99.9
PCO2:23.7
pH:7.29
HCO3:9.7
PO2:48.6
PCO2:20.5
pH:7.196
HCO3:7.5

39. BFMP:negative
Typhoid test :negative
Leptospira serology:non reactive
Creat:288
Indirect bilirubin:23
Direct:13
ALT:4190
AST:6439
ALP:551
LDH:4464
Plasma lactate:10.4mmol/l
Blood C+S:no growth
Meiloidosis serology :pending
Dengue serology: IgM detected
Stool occult blood:negative
CK:1143
CXR(discuss with radiologist)
right pleural effusion with fluid in the oblique fissure,may represent chest infection