Case Management 2 Facilitators:

Dato Dr. Sree Raman

Dr. Lim Chew Har

Dr. Ho Bee Kiau

26/6/08Klinik Kesihatan

FEMALE 60 year old C/O: Fever for 3 days Dizzy and lethargy Joint pain and myalgia Nausea but no vomiting

PMH: DM and HPT. Not on treatment O/E:

T=38 C BP=120/70

Cont..

Fever ? Cause Treatment:

Paracetamol Cefaclor 375mg bd

Q1: What is your comment on the case management?

Answer Q1: 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

Page 16

27/6/08 (Day 4 of fever)Klinik Kesihatan

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?

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

WARNING SIGNS

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 am- Saturday)

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

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

The BP, Pulse monitoring must be continued while in the ambulance and patient must be accompanied by MO/MA

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 HypertensionDH: 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

Plan for fluid therapy should be documented

This patient should be admitted to HDW or ICU for close monitoring and management

Answers Q5

Day 5 (1630) ( 4 hours defervescence )

BP:94/73mmHg PR:101/min

T:37’C SPO2 97%G/M:17.9mmol/lCVS: DRNMLungs :clearAbdomen: soft,non

tender PR: yellowish stool, no malena

Twbc:4.6 x109

Hb:15.4g/dl HCT:46.5Plt: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 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?

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

Answers Q7

Day 5 (2130) ( 9 hours defervescence)

BP:102/68mmHg PR:101/minT:37’C RR 24/min SPO2 95% O2 2l/minLung: crepitation bibasal Abdo: SoftUrine 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

PCO2:23.7PO2:99.9

- 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 statIV cocktail stat & 50ml NaHCO3Reduce IV drip to 4pints/24 hoursInsulin infusion 3u/hrCVP attempted x 2 but failed

Q9 : Would you have attempted central line insertion ?

• 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.

Answer Q9

Day 6 (0810am) ( 20 hours defervescence)

On dopamine 4cc/h. Tailing down dose

Examination:

Alert GCS 15/15 RR 22/min,pink,no jaundiceBP:178/83mmHg PR:110/min T:37’CLungs: crepitation at the basesAbdomen: tenderness at the epigastriumBleeding at venepunctureUrine output –anuric since 12 midnight

Ix:ABG:PH:7.29 HCO3:9.7 PO2:98BUSE:17.7/134/.6.9/106

RESULTS:

Date/result

28/6 (Day5)1520

28/620.30

29/6(Day 6)0400

29/61000

TWBC 4.6 7.7 13.7 12.7

HB 15.4 16.5 12.3 11.2

HCT 46.5 48.3 37.6 33

PLT 4 16 15 17

BUSE 13.6/135/6.8/104

16.2/134/7.0/105

16.9/136/5.6/104

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 HCO3:7.5CBD: urine 10cc onlyPatient :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 29/6

PT/ APTT INR:2.48Ratio:3.84

ABG pH:7.31HCO3:11.7PO2:99.9PCO2:23.7

pH:7.29HCO3:9.7PO2:48.6PCO2:20.5

pH:7.196HCO3:7.5

BFMP:negativeTyphoid test :negativeLeptospira serology:non reactiveCreat:288Indirect bilirubin:23Direct:13ALT:4190AST:6439ALP:551LDH:4464Plasma lactate:10.4mmol/lBlood C+S:no growthMeiloidosis serology :pendingDengue serology: IgM detectedStool occult blood:negativeCK:1143CXR(discuss with radiologist) right pleural effusion with fluid in the oblique fissure,may represent chest

infection