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

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

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?

DATE / TIME

20/5 21/5

7PM 7AM 5PM

HCT 39.9 39.3 35.5

HB 14.4 13.6 11.8

PLT 15 19 13

WCC 2.2 2.1 4.2

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

DATE / TIME

20/5 21/5 22/5

7PM 7AM 5PM 12AM 7AM 12PM

HCT 39.9 39.3 35.5 32.5 29.5 30.6

HB 14.4 13.6 11.8 11.7 10.4 10.4

PLT 15 19 13 22 26 24

WCC 2.2 2.1 4.2 7.6 12.9 14.9

23

Comment on the usage of frusemide at this stage

24

Date 20/5 21/5 22/5

T. Bil 22 53 107

ALT 407 491 2476

AST 1230 1573 -2*

CK 359 - -

LDH 1912 - -

Creat 0.07 0.03 0.06

PTT - 76.6 62.4

INR - 1.3 2.11

25

What else is happening

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

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

28

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

29

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

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

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

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

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

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

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