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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
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Social History Working in Taman University ( dengue area )
in a textile factory Recently engaged Currently lives with family
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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
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Diagnosis Dengue Fever Differential : Acute gastroenteritis FBC from A&E :
Hemoglobin 144 G/L Hematocrit 39.9 Platelet 15 G/L WCC 2.2
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Investigations taken
– FBC– BUSE/ Creatinine/ LFT– Dengue Serology– BFMP x 3– CXR– Stool
• Ova and cyst, C & S
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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