Case Management 2
Facilitators:
Dato Dr. Sree Raman
Dr. Lim Chew Har
Dr. Ho Bee Kiau
26/6/08
Klinik Kesihatan
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FEMALE 60 year old
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C/O: Fever for 3 days
Dizzy and lethargy
 Joint pain and myalgia
 Nausea but no vomiting
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PMH: DM and HPT. Not on treatment
O/E:
T=38 C
 BP=120/70
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Cont..
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Fever ? Cause
Treatment:
 Paracetamol
 Cefaclor 375mg bd
Q1: What is your comment on the case
management?
Answer Q1:
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Page 16
A Stepwise approach on outpatient
management of dengue infection is
important
Step 1: Overall assessment
1. History
2. Physical examination
3. Investigations
Step 2 : Diagnosis, disease staging and
severity assessment
Step 3 : Plan of management
27/6/08 (Day 4 of fever)
Klinik Kesihatan
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Patient came back to KK the next day, still c/o fever with
diarrhea, vomiting and epigastric pain, feeling lethargy.
Seen by MA, O/E T=38.5 C, BP 110/65, PR 100/min,
hydration fair, PA: soft, mild epigastric tenderness.
Diagnosis: AGE with gastritis TRO DF
FBC: Hb 10.3, Platelet count 120 (HCT 41.5%)
TCA cm to repeat FBC
Q2: a) What are the warning signs?
b) Would you have admitted this patient?
Warning signs
Answer Q2(a):
Page 17
WARNING SIGNS
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (pleural effusion,
ascites)
• Mucosal bleed
• Restlessness or lethargy
• Liver enlargement > 2 cm
• Laboratory : Increase in HCT concurrent
with rapid
decrease in platelet
Answer Q2(b):
CRITERIA FOR HOSPITAL
REFERRAL / ADMISSION
Page 18
The decision for referral and admission should depend
on
the Total Assessment:
1. Symptoms :
• Warning signs
• Bleeding manifestations
• Inability to tolerate oral fluids
• Reduced urine output
• Seizure
2. Signs :
• Dehydration
• Shock
• Bleeding
• Any organ failure
3. Special Situations :
• Patients with co-morbidity e.g. diabetes, hypertension,
ischaemic heart disease, coagulopathies, morbid obesity,
renal failure, chronic liver disease, COPD, haemoglobinopathy
• Elderly (<65 years old)
• Pregnancy
• Social factors that limit follow-up e.g. living far from health
facility, no transport, patient living alone
4. Laboratory Criteria:
Rising HCT accompanied by reducing platelet count
28/6/08 (Day 5,10:00 amSaturday)
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Ambulance call. Brought to KK at 12:05pm
Seen by MA
H/o:
 Fever 5 days, still has diarrhea and vomiting
 Headache and joint pain
 Epigastric pain for 2 day
 Dark sticky stool 2/7
O/E:
 BP unrecordable. Alert conscious
 Pulse: fast and small volume
DIAGNOSIS :
UPPER GIT BLEED WITH SHOCK
SECONDARY TO DHF OR PEPTIC ULCER
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Ix: RBS=21.4mmol/L
Treatment: IVD- Hartman’s 3pint via 2 IV
lines
Wrote a referral letter
Referred to hospital and accompanied by
JM
Q3. What could have been done by the
health provider at KK?
Answer Q3:
Page 18
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The BP, Pulse monitoring must be continued while in
the ambulance and patient must be accompanied by MO/MA
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At 12:35pm, the patient was transferred to
Hospital A (as requested by the family because
one of their family member worked at Hospital A
and she was on follow up for DM there)
Arrived at Hospital A at 12:55pm
JM went to the casualty and showed referral
letter to the counter staff at casualty. Case was
not accepted because no bed available
Case was sent to General Hospital
A+E General Hospital
(Day 5,1.30PM – 2 hours defervescence):
C/O:
- Fever x 5/7. Settled today
- Diarrhoea (5x/day) & black tarry stool for 2 days
- Vomiting with epigastric pain
- Giddiness, lethargic, myalgia
- No hematemesis
- Neighbour admitted for dengue, still in ward
PMH: Diabetes Mellitus and Hypertension
DH: Metaprolol 50mg bd and ramipril
Glicazide 80mg bd and simvastatin 20mg
Took NSAIDS for shoulder pain & myalgia
Examination:
Wt 55kg
Pink, alert and conscious
BP:90/68mmHg PR:65/min T:37’C
SPO2:98-100% Cold peripheries. No rash
Capillary refill time > 2sec
CVS: S1S2 ESM at left sternal edge
Lungs : clear
Abdomen: soft, mild epigastric tenderness
PR: malena
Glucometer :14.9mmol/l
Q4. What is your diagnosis?
Answer Q4:
Dengue Shock syndrome ( Grade 3)
with upper GI bleed.
Underlying uncontrolled DM
Diagnosis :
1) Hypotension secondary to AGE
2) Uncontrolled DM
3) UGIT bleed
Management:
- Admit general ward
- Given 1pint Hartman fast
Investigations:
FBC, BUSE , RBS, Stool C&S
Q5. Comment on the management
Answers Q5
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Plan for fluid therapy should be
documented
This patient should be admitted to HDW
or ICU for close monitoring and
management
Day 5 (1630) ( 4 hours defervescence )
BP:94/73mmHg
PR:101/min
T:37’C SPO2 97%
G/M:17.9mmol/l
CVS: DRNM
Lungs :clear
Abdomen: soft,non tender
PR: yellowish stool,
no malena
Twbc:4.6 x109
Hb:15.4g/dl HCT:46.5
Plt:4 x109
Urea 13mmol/l Na 125 K 4.1
INR 1.7 APTT 59
ECG: Normal
Diagnosis:
1) Fever with severe thrombocytopenia
Dengue haemorrhagic fever Grade III (CriticalPhase)
2) DM uncontrolled
Mx:
- Start iv dopamine 150mg in 50cc run 5cc/h
- SC Actrapid 10 u tds
- IV fluid 6 pint N/S over 24 h
- to transfuse 4 u platelet
- monitor I/O
Q6.
Explain why Hb and HCT in this patient
was not as low as expected.
Comment on the use of dopamine at this stage.
Answers Q6
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Hb and HCT were relatively high (inappropriate)
considering patient had GIT bleed.
Her high HCT was due to hemoconcentration as a
result of plasma leakage during this critical phase.
It was expected that Hb and HCT would drop once IV
fluid therapy being given and hemoconcentration
improved.
The use of inotropic/vasopressor support at this stage
( when the patient is still hypovolaemic) may further
worsen the tissue hypoxia, due to vasoconstriction effect
of the dopamine.
Q7: Do you agree with the fluid
therapy and platelet transfusion?
Answers Q7
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The IV fluid regime was inadequate. IV fluid
therapy should be initiated with resuscitation
regime as patient was in shock.
Resuscitation rate : 10-20ml/kg fast with
crystalloid for the first 2 cycles then colloid if
hemodynamically not improved.
Meanwhile packed cell should be made
available as patient was bleeding. Other
blood products such as platelet and FFP may
be given
Day 5 (2130) ( 9 hours defervescence)
BP:102/68mmHg
PR:101/min
T:37’C RR 24/min
SPO2 95% O2 2l/min
Lung: crepitation bibasal
Abdo: Soft
Urine output: 10ml/hr
Diagnosis
- DSS
- Uncontrolled DM
- Acute renal failure
- Fluid overload
WCC 7 Hb 16.5 Hct 49
Platelet 16,000
-BUSE:13.6/135/6.8/104
16.2/134/7.0/105
-Amylase:69
-ABG:
ph:7.3 HCO3:11.7
PCO2:23.7
PO2:99.9
- Chest X ray: pleural
effusion on R side
Q8 : What would you do now?
Answers Q8
• Fluid resuscitation was inadequate as evidenced by
persistently raised HCT and severe metabolic acidosis.
• The patient had ongoing plasma leakage with pleural
effusion and further fluid resuscitation would most likely
lead to worsening of respiratory function so intubation was
indicated.
• The patient should have been referred to intensive care unit
for consideration of ICU admission.
• Early recognition and treatment of shock is essential
• Management of DSS is a medical emergency and
requires prompt and adequate fluid replacement
• Early and effective replacement of plasma losses
results in a favorable outcome, so consider early referral
to ICU
• Severe metabolic acidosis is a sign of prolonged shock
and tissue hypoxia
• In general, respiratory support should be considered early
in a patient’s course of illness and should not be delayed
until the need arises.
Treatment:
IV lasix 40mg stat
IV cocktail stat & 50ml NaHCO3
Reduce IV drip to 4pints/24 hours
Insulin infusion 3u/hr
CVP attempted x 2 but failed
Q9 : Would you have attempted central line
insertion ?
Answer Q9
• Volume resuscitation does not require a central venous
catherisation (CVC) if sufficient peripheral intravenous
access can be obtained.
• When CVC is indicated it should be inserted by a
skilled operator, preferably under ultrasound guidance
if available.
• Subclavian vein cannulation should be avoided as far
as possible.
Day 6 (0810am) ( 20 hours defervescence)
On dopamine 4cc/h. Tailing down dose
Examination:
Alert GCS 15/15 RR 22/min,pink,no jaundice
BP:178/83mmHg
PR:110/min
T:37’C
Lungs: crepitation at the bases
Abdomen: tenderness at the epigastrium
Bleeding at venepuncture
Urine output –anuric since 12 midnight
Ix:
ABG:PH:7.29 HCO3:9.7
BUSE:17.7/134/.6.9/106
PO2:98
RESULTS:
Date/result 28/6
(Day5)
1520
TWBC
HB
HCT
PLT
BUSE
28/6
20.30
29/6
(Day 6)
0400
4.6
7.7
13.7
15.4
16.5
12.3
46.5
48.3
37.6
4
16
15
13.6/13 16.2/134/ 16.9/13
5/6.8/1 7.0/105
6/5.6/1
04
04
29/6
1000
12.7
11.2
33
17
Diagnosis:
1) Dengue shock syndrome with sepsis
2) Acute renal failure secondary to (1)
3) Persistent hyperkalaemia-cocktail x 2
4) Thrombocytopenia
6) Uncontrolled DM
Mx:
- Add Fortum 1g od
- Iv Azithromycin 500 mg od
- IV fluid 1pint/24 hours
- Increase insulin to 4 u /h -1H g/m (aim 6-8mmol/l)
- iv sodium bicarbonate 50cc over ½ h
- iv cocktail stat kiv hyperkalaemia –for dialysis
- iv ranitidine 50mg tds
- Put on HFMO2 10L/min
1030am ( 22 hours defervescence) :
BP dropping to 98/28mmHg
Mx:
Started on iv noradrenalin 8 mg in 50cc D5% run at
2cc/h
12 noon ( 24 hours defeversence)
Reviewed ABG:PH :7.196 HCO3:7.5
CBD: urine 10cc only
Patient :acidotic breathing
Case noted to specialist:
- to transfused platelet 4 u than proceed with peritoneal
dialysis
- refer anaest
Patient then desaturated
o/e:
- Tachypnoeic,gasping
- Emergency intubation
- BP recordable after started on tripple inotropic
agent:81/53mmHg
pulse rate:154/min-weak
cold peripheries
- Pupil dilated and non reactive
Pt asystole then
CPR done-3 ampoules of atropine and
adrenalin given but not reverted.
Confirmed death:2.30pm ( 26 hours
defervescence)
Cause of death:septicaemic shock
Result / date
28/6
29/6
PT/ APTT
ABG
29/6
INR:2.48
Ratio:3.84
pH:7.31
HCO3:11.7
PO2:99.9
PCO2:23.7
pH:7.29
HCO3:9.7
PO2:48.6
PCO2:20.5
pH:7.196
HCO3:7.5
BFMP:negative
Typhoid test :negative
Leptospira serology:non reactive
Creat:288
Indirect bilirubin:23
Direct:13
ALT:4190
AST:6439
ALP:551
LDH:4464
Plasma lactate:10.4mmol/l
Blood C+S:no growth
Meiloidosis serology :pending
Dengue serology: IgM detected
Stool occult blood:negative
CK:1143
CXR(discuss with radiologist)
right pleural effusion with fluid in the oblique fissure,may represent chest
infection