1. Chua Hock Hin, HSAJB Suresh Kumar, HSB
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?
Insert graph

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
Calculate hours of defervescence

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 : 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
Group screen and hold required for all DHF grade3&4

22. DATE / TIME
20/5
21/5
22/5
7PM
7AM
5PM
12AM
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
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 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 am, 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
Blood C&S (22/5/08)  No sample
Blood C&S (23/5/08)  No growth