Dengue ( A & E).docx

DOA : 24/1/2015 ( 4 days ago)

which did not manage to alleviate her symptoms and on that night, she experienced facial and body itchiness although there were no visible rashes or any skin lesions. Her mother noticed that he child looked very ill and appeared drowsy which then prompt her to the patient to the emergency department at HSNZ.

DOC : 24/1/2015( on the same day)

Systemic Review: ( is unremarkable)

Patient information Name : Nabilah bt azlan , 18 year old malay girl single, stays at rusila, Marang and works as a waitress at Pasir Panjang

Chief complaint : Ptient came in due to headache for 2 days and fever on the day of admission.

1) General: was fever, lethargy and loss of

HOPI :

2) Cardiovascular system: absence of chest

Patient was apparently well until 2 days ago, when she developed a very bad headache which was sudden on onset, episodic, each lasting a few minutes with a pain 4 to 5, on bilateral sides ,was pulsatile in nature. She tried to relieve the pain by taking panadol which managed to subside the pain for the day. The head ache was also accompanied by lethargy, she found that she not have the energy to carried out her daily activities as usual and was not able to go to work that day. The next day the headache and lethargic feeling still persisted, her headache however seem to have gotten worse with a pain score of 8 and this time around she also felt pain on eye movement. Around evening she developed a sudden high grade fever at 39 degree measured at home with no chills and rigor, it was continuous in pattern and was associated with coryzal symptoms, productive cough with yellowish sputum with no blood stains, generalized body pain esp at her back and loss of appetite. Otherwise,patient denied having nausea, vomiting, diaarhea, shortness of breath, joint pain, abdominal pain or any bleeding tendencies. She however mentioned that there were recent fogging at the place where she works but other than that there is no hx of travelling or involment in any recreational activity like swimming, or jungle trekking or any having any TB contact. Her parents then brought her to the pharmacy and there they gave her panadol, cough mixture and flu medicine, all of

appetite but no weight changes

pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea

3) Respiratory system: presence of coryzal symptoms and productive cough, no hemptysis

4) Nervous system: Presence of headache,but no syncopal attacks, seizure, blurring of vision, weakness or numbness of the extremities

5) Urinary system: absence of dysuria, polyuria,nocturia and frequency

6) Gastrointestinal system: no indigestion, nausea and vomiting or change in bowel habits

7) Musculoskeletal system: presence of musche ache but no bone and joint pain

Physical examination Nabilah is a small built girl . She was alert and conscious, was lying on the bed. She was not in any respiratory distress during clerking however she appeared to be very lethargic and slightly drowsy. There were canula on the dorsum of each hand which was connected to drip bags. Vital signs Blood pressure :84/51 mm hg Pulse rate :147 beats per minute, low volume and regular rhytm Temperature:39.2 Respiratory rate : 18 breaths per minute Pain score :0 General Observation: Hands : Slighlty pale, cold with no cyanosis and crt was 2 seconds. On the arms there were no rashes. Face : No conjuctival pallor, her lips were dry otherwise there was no central cyanosis, mucosal bleed and the oral hygiene was good and overall there were no rashes on the face either. Neck : there were no cervical Ln enlargement. Trachea was centrally located. Lower limbs : there were no pitting edema

Summary Nabilah, 18 year old girl with hx of being in a dengue prone area came in with worsening headache and lethargic for 2 days and continuous high grade fever on the day of admission which manifested with coryzal symptoms, productive cough, generalised body pain, back ache, loss of appetite and facial and body itchiness. On physical examination, patient was found to be hypotensive, febrile with tachycardia and low pulse volume along with pale and cold peripheries and capillary refill time was 2 seconds, her lips were dry and she appeared drowsy. Otherwise the physical examination was unremarkable. Provisional diagnosis : Dengue fever in decompensated shock Differential diagnosis 1) Malaria 2) Leptospirosis 3) Tuberculosis Investigation 1) Full blood count 2) Blood urea and serum electrolyte/ serum creatinine 3) Arterial blood Gas 4) lactate level 5) liver function test 6) Dengue combs test 7) chest x-ray 8) ECG 9) malaria test Management

Full blood count result :

ecg : sinus tachycardia Chest x-ray : Normal Blood urea and serum electrolyte: Urea Sodium Potassium Chloride Creatinine

2.6 mmol/l ( LOW) 135 3.6 102 47

2.8-7.2 133-145 3.5-5.1 96-108 45-84

Arterial blood gas : ph partial pressure of co2 partial pressure of o2 ooxygen saturation bicarbonate base excess

7.37 38.2

7.35- 7.45 35-45

43 ( CRITICAL LOW) 74( LOW)

80-100

21.4( LOW) -3.0

22-26

95-98

Liver function test: total protein albumin globulin a/g ratio ALP ALT bilirubin total

70 43 27 1.6 85 14 19.6

57-80 35-52

47-162 <45 5-21

Prothrombin time and activated prothrombin time : PT : 14.6 APTT : 32.9 Lactate: High ( result : 2.62 mmol/L) -0.50-2.20