CASE PRESENTATION - 4. Day 3 onset of fever, 0730am C/O: Fever-3 days Nausea and vomiting Myalgia....
-
Upload
ethel-chandler -
Category
Documents
-
view
214 -
download
0
Transcript of CASE PRESENTATION - 4. Day 3 onset of fever, 0730am C/O: Fever-3 days Nausea and vomiting Myalgia....
CASE PRESENTATION - 4
Day 3 onset of fever, 0730amC/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 GombakCame back to Kelantan on D2 of feverS/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 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX (Day 5)
0830 1200
WCC 7.8 7.1
Hb 14.5 16.6
Hct 44.0 50.0
Platelet 56 13
Urea 9.0
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 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX 1730 2140
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
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 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX 1730D5
2140D5
0100D6
WCC 8.3 8.9 17.8
Hb 13.2 14.1 13.0
Hct 38.4 42.0 41
Platelet 7 5 7
Urea 12.0 13
Creatini
300
Lactate 11.2
INR 1.8
APTT 112
AST 1213
ALT 2303
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
IX 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX 2140D5
0100 0600D6
WCC 8.9 17.8 22.8
Hb 14.1 13.0 10.0
Hct 42.0 41.0 28
Platelet 5 7 7
Urea 13 23
Creatini
300 480
Lactate 11.2 11.3
INR
APTT
AST 1213
ALT 2303
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 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX 1100D6
1500D6
2200D6
WCC 18.3 18.9 17.8
Hb 12.0 12.1 11.0
Hct 34.4 42.0 33.1
Platelet 27 25 27
Urea 8.0 7.8 6.5
Creatinine
120
Lactate 4.0
INR 1.6
APTT 71
AST 1713
ALT 1203
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 1730 2200
WCC 8.3 8.9
Hb 13.2 14.1
Hct 38.4 42.0
Platelet 7 5
Urea 12.0
Lactate 11.2
INR 1.8
APTT 112
IX D8 0600
1000 1600
WCC 5.21 3.84 4.1
Hb 11.6 12.1 9.0
Hct 34.4 36.0 27.1
Platelet 25 15 27
Urea 6.0 6.8 6.5
Creatini
90
Lactate 3.7
INR 1.6 1.8
APTT 71 60
AST 1868
ALT 833
Q9: Can you comment on borderline Dengue IgM serology?
FINAL CAUSE OF DEATH
DENGUE SHOCK SYNDROME WITH
SEPTICAEMIA