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CASE PRESENTATION - 4

CASE PRESENTATION - 4. 26/M/F, university student, staying at Gombak Came back to Kelantan on D2 of fever. S/B MA at A&E, DH. Day 3 onset of fever, 0730am C/O: Fever-3 days Nausea and vomiting Myalgia. O/E Comfortable Pulse 98/min BP= 98/60mmHg T=37.5

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CASE PRESENTATION - 4

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  1. CASE PRESENTATION - 4

  2. 26/M/F, university student, staying at GombakCame back to Kelantan on D2 of fever S/B MA at A&E, DH Day 3 onset of fever, 0730am C/O: Fever-3 days Nausea and vomiting Myalgia. O/E Comfortable Pulse 98/min BP= 98/60mmHg T=37.5 Lungs -clear

  3. Given IV fluid 1pint N/S fast. • Repeat BP 102/60 • Plan: FBC • Allow discharged (before review of FBC)

  4. Q1: What is the pitfall in the management ?

  5. District Hospital Day 5 (1430, 31 hours defervecence) (Referral letter) Admitted yesterday. • C/O: fever for 4 days , vomiting and abdominal pain headache and fainting episodes No bleeding No diarrhoea • 2 siblings also had fever. Still at home.

  6. Cont……. • Admitted for 24 hours. BP =80-90/50-60mmHg, HR=105/min Leptospirosis TRO dengue • IV fluid 1pint N/S bolus followed by 5 pint N/S over 24 hours • IV C Penicillin 2.0 mega 6hourly • Referred for persistent thrombocytopenia

  7. Q2: Comment on the referral letter?

  8. Q3: Comment on diagnosis • Q4: How would you manage? • Q5: What other investigations would you request?

  9. GH: Day 5 (1630,33 hours defervecence) • Has PV bleed. 4 pads soaked today • Examination: Obese wt 79kg Alert but restless Afebrile BP 80/60 PR 98/min RR 22/min SPO2:98% on O2 nasal prong Generalized macular rash Lungs: clear Abdomen: soft , mild tenderness Hess test: POSITIVE

  10. Assessment : DSS • Fluid resuscitation: 10ml/kg bolus given for 2 cycles (1L N/S then 1L voluven). Continued with 1.5 IV fluid maintenance. • ABG: PO2 105 PCO2 25 HCO3 15mmol/l

  11. Day 5 (22.00, 37 hours defervesence) • More restless. BP 146/110mmHg • Pulse 105/min RR 25/min. SpO2 95% on HFL • Lungs: Rhonchi. Bilateral pleural effusion • Abdomen: Distended and tender. Ascites present • Left ankle- bruises

  12. Day 5 (22.30) • Chest X ray: Bilateral pleural effusion and collapsed consolidation of left lower lobe • ABG: PO2 130 PCO2 21 HCO3 13mmol/l • GXM -3 pint packed cell • 6hourly FBC/BUSE • Blood C&S • Echocardiogram: good LV function EF 68%

  13. Q6: Discuss on hemodynamic status of this patient? • Q7: Would you transfuse blood and blood products?

  14. Day 5 (23.30) • BP 82/60 Pulse 112/min RR 30/min • Treatment: IVD 2 pints NS/2H (6ml/kg /hour) 2 pints packed cell transfused • Refferred to anesthetist: NO BED IN ICU • Q7: How would you manage the patient?

  15. Day 6 (0230) • More restless and tachypnoeic • Ventilated in HDW • Urine output: 20ml/hour • Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy)

  16. Day 6 (0900) Transferred to ICU • Noted blood clots from the ETT and RT-coffee ground aspirate • Bleeding from nasal and oral cavity and from the puncture sites • BP=105/55 HR 98/min. • Urine output (20ml/h) • ABG: pH 7.096 pCO2 18.4 pO2 192.9 HCO3 5.5 BE -24.2

  17. CVVHDF commenced • Blood transfusion: 4 pints PC, 4u platelet, 4u FFP • Fluid therapy reduced to 500ml/24 hours • Referred to gastro team

  18. Day 7 (0230) • Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy)

  19. Q9: Did you agree with the gastro referral? • Q10: Why did you think the patient deteriorated despite stable BP?

  20. Day 8(Recovery phase:1000) • BP:100/50mmHg on NA infusion. T 35C • HR 102/min. Temp=36C. Ventilated. Anuric. • CXR: worsening pleural effusion, ARDS features • ABG: Ph 6.9, PCO2 58 P02 90 HC02 9 WCC 3.84 Hb 12.2 HCT 36.2 Platelet 16 • Hematologist: 2 cycles DIVC regimes and IV tranxanemic acid.

  21. Day 8(1800) • General condition deteriorating further: • BP lowish despite 4 max intropes • Bleeding from oral and nasal cavity, ETT • Generalized oedema, peripheral cyanosis • Pupils fixed and dilated • Confirm death at 2025h • Cause of death: DENGUE SHOCK SYNDROME

  22. Day 9 (0930) • Dengue IgM: (D5) borderline • Blood C&S: D5: No growth D7:Kleb Pneum • Urine C&S: D7 Kleb Pneum • TA C&S: Kleb Pneum

  23. Q9: Can you comment on borderline Dengue IgM serology?

  24. FINAL CAUSE OF DEATH DENGUE SHOCK SYNDROME WITH SEPTICAEMIA

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