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Case Presentation 1

Case Presentation 1. Chua Hock Hin, HSAJB Suresh Kumar, HSB. Presenting Symptoms ( Admit 20/5/08 8pm ). V.S / Indian / Female / 39 years Fever x 4/7 a/w chills but no rigor s Diarrhoea and vomiting x 2 days No bleeding tendency No SOB No chest pain

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Case Presentation 1

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

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

  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. 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. What is the diagnosis?

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

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

  9. 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 Plan of management

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

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

  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. Monitoring in dengue • Comment on the review frequency

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

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

  17. Comment on the use of ABG at this stage

  18. What will be correct diagnosis of the current patient condition?

  19. 36 hours defervescence( 22/5/08, 8am ) – Day 6 fever onset • Still abdominal pain T : 38oC • 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. What do you think is happening? • What will be the appropriate management at this stage?

  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. Comment on the usage of frusemide at this stage

  23. What else is happening

  24. 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

  25. Ultrasound report • U/S Abd done 22/5/08 4.30 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

  26. D3 admission (23/5/08, 8am )- at 60 hours post defervescence • Abdominal pain persistent • Clinically : • Septic looking; T : 37.4oC 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

  27. Investigation results • ABG – worsening compensated metabolic acidosis pH 7.36 HCO314 BE -9 pCO2 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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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