CASE PRESENTATION - 4. 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.

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Presentation transcript:

CASE PRESENTATION - 4

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 26/M/F, university student, staying at Gombak Came back to Kelantan on D2 of fever S/B MA at A&E, DH

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

Q1: What is the pitfall in the management ?

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.

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 IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX (Day 5) WCC Hb Hct Platelet5613 Urea9.0 Lactate INR APTT

Q2: Comment on the referral letter?

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

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

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

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

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% IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112

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

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?

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) IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX1730 D D D6 WCC Hb Hct Platelet757 Urea Creatini300 Lactate11.2 INR1.8 APTT112 AST1213 ALT2303

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 pCO pO HCO3 5.5 BE IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX2140 D D6 WCC Hb Hct Platelet577 Urea1323 Creatini Lactate INR APTT AST1213 ALT2303

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

Day 7 (0230) Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy) IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX1100 D D D6 WCC Hb Hct Platelet Urea Creatinine120 Lactate4.0 INR1.6 APTT71 AST1713 ALT1203

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

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.

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

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 IX WCC Hb Hct Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX D WCC Hb Hct Platelet Urea Creatini90 Lactate3.7 INR APTT7160 AST1868 ALT833

Q9: Can you comment on borderline Dengue IgM serology?

FINAL CAUSE OF DEATH DENGUE SHOCK SYNDROME WITH SEPTICAEMIA