ACCIDENT AND EMERGENCY POSTING

CASE WRITE UP 1

Name : Sangari a/p R. Sarkuna Singam

Student ID : 1001439079
Year 4, Group : 1
Date : 30/1/2016
Patient Information
Name : Nabilah bt azlan
Age : 18 year old malay girl
Address : Rusila, Marang
Occupation : Waitress at Pasir Panjang
Date of admission : 24/1/2015
Date of clerking : 24/1/2015( on the same day)

Chief complaint : Patient came in due to fever on the day of admission.

History of presenting illness:

Patient was apparently well until a day prior to admission when she develop headache and
lethargy which was able to be managed with the use of panadol however the next day,
around evening she developed high grade fever around 39 degree which was continuous in
pattern with no chills or rigors. It was associated with coryzal symptoms, productive cough
with yellowish sputum, generalized body pain especially at her back, muscle pain, joint pain,
retro-orbital pain, facial and body itchiness and loss of appetite. Otherwise, patient denied
having nausea, vomiting, diarrhoea, shortness of breath, abdominal pain, rashes or any
bleeding tendencies. She however mentioned that there was recent fogging at the place where
she works but other than that there is no history of travelling or involvement in any
recreational activity like swimming, or jungle trekking or any having any TB contact. Before
coming to the emergency department, patient took over the counter drugs like panadol, flu
medication and cough syrup was unable to alleviate her symptoms.
Systemic Review

General : Presence of fever, lethargy and loss of appetite but no weight changes

Cardiovascular system : No chest pain, shortness of breath, orthopnea or paroxysmal

nocturnal dyspnoea

Respiratory system : Presence of coryzal symptoms and productive cough, no hemoptysis

Central Nervous system : Presence of headache but no loss of consciousness , seizure or

change in mental status

Urinary system : No hematuria, dysuria or oliguria

Gastrointestinal system : No nausea, vomiting, diarrhoea or bloody stools

Musculoskeletal system : Presence of muscle pain and joint pain

Past medical history

She has no known medical illness like asthma or hypertension and this is her first
hospitalization.

Drug and Allergy History

Other than the drugs mentioned, she did not take any other drugs or herbal medications and
has no known drug or food allergy.

Menstrual History

Patient is currently in her second day of menstruation with normal flow and there is no
menorrhagia or dysmenorrhea.

Family History

Both her parents and two siblings are well and there is no family history of chronic or
inherited illnesses in the family.

Social History

Patient is working at Pasir Panjang ( a dengue prone are) but otherwise she does not smoke,
take alcohol or recreational drugs.
Physical Examination

Nabilah is a small built girl. She appeared drowsy and was lying on her bed. She was not in
any respiratory distress during clerking and there was cannula on the dorsum of each hand.
The left one connected to a drip bag.

Vital Signs

Blood Pressure : 84/51 mmHg Weight : 42 Kg

Pulse rate : 147 beats per minute, low volume, regular Height : 1.53 m

Respiratory rate : 18 breaths per minute Body Mass Index : 17.9kg m

Temperature : 39C
Pain score : 0

General Observation:
Hands : Slighlty pale, cold with no cyanosis and capillary refill time 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 lymph node enlargement. Trachea was centrally located.
Lower limbs : There were no pitting edema

Abdominal Examination
Inspection : Abdomen is not distended, no scars, moves with respiration and umbilicus is
centrally located and inverted.
Palpation: Soft and non-tender. No hepatosplenomegaly and kidneys are not ballotable.
Percussion: Was resonant and shifting dullness was negative.
Auscultation : Normal bowel sounds were heard.

Respiratory System Examination

Inspection: Chest moves symmetrically with respiration and there is no signs of laboured
breathing.
Palpation : Trachea is centrally located. Chest expansion is equal and vocal fremitus is
normal.
Percussion : Equally resonant on both sides.
Auscultation : Normal air entry on both sides and there is no added sounds like crepitations
or wheeze. Vocal resonance is normal.
Cardiovascular System
Inspection : No chest deformity or scars.
Palpation : Apex is felt at 5th intercostal space, mid-clavicular line. No heaves or thrills.
Auscultation : Normal first and second heart sound heard.

Central Nervous System

No abnormal posture or fasiculations. Tone, power and reflexes are normal on both
extremities. Higher cortical function and sensory function is intact.

Summary

Nabilah, a 18 year old girl with history of being in a dengue prone area came in with
continuous high grade fever on the day of admission which was associated with headache,
lethargy, 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

Supporting Points :

- From dengue prone area, febrile,headache, muscle ache, joint ache,lethargy,coryzal

symptoms and cough ( Signs of dengue)
- Cold peripheries, prolonged capillary refill time, low peripheral pulse, hypotension,
tacycardia ( Signs of decompensated shock)

Differential Diagnosis :
1) Septic shock due to pneumonia

Supporting points :
- Febrile, coryzal symptoms, productive cough with yellowish sputum, lethargy and loss of
appetite
-Cold peripheries, prolonged capillary refill time, low peripheral pulse, hypotension,
tacycardia ( Signs of late septic shock)
2) Malaria

Supporting points :
- Febrile, headache, muscle pain, lethargy and loss of appetite

Investigations
1) Full blood count- To detect any white blood count, platelet and hematocrit abnormalities.
2) Dengue Rapid Combo test
3) Blood urea and serum electrolyte/ Serum creatinine- To detect fluid and electrolyte
abnormalities and signs of kidney injury due to shock.
4) Venous blood gas - To detect metabolic acidosis in this patient.
5) Serum lactate- To assess the degree of inadequate tissue perfusion.
6) Liver function test- Took look for any dengue related complications.
7) Chest x-ray- To look for pleural effusion and heart abnormalities.
8) Electrocardiogram ( ECG)- To detect any heart abnormalities, electrolyte imbalance or
kidney injury.

Management
At the emergency department
1) Do triage checklist at registration counter and vital signs must be taken.
2) Clinical assessment of the airway, breathing and circulatory status must be done.
3) Necessary lab test should be done. Some of the tests are mentioned above.
4) If admission is required, the patient must be started on appropriate fluid therapy either
orally or intravenously.
5) Vital signs and ongoing fluid losses should be monitored strictly.
Parameters to be monitored : Appetite, oral intake, presence of any warning sign, blood
pressure, pulse pressure, respiratory rate, oxygen saturation, neurological status, urine output
and full blood count ( Daily until white blood count start to increase followed by platelets)
6) Total dengue assessment should be done using the checklist.
7) Nearest district health office should be informed.
Outpatient management
1) Dengue assessment checklist must be filled.
2) The nearest district health office should notified followed by disease notification form.
3) If admission is indicated
- The patient should be stabilized before transfer
- The receiving hospital/ emergency department should be informed before transfer.
4) If admission is not indicated
- Daily follow up is necessary especially from day 3 of illness onwards until the patient
becomes afebrile for at least 24- 48 hours without antipyretics
- Patient and their caretakers should be advised on how to take care of the patient at home.

What should be done?

- Adequate bed rest and fluid intake ( more than 8 glasses or 2 litres)

- Take paracetamol ( not more than 4 gram per day)

- Tepid sponging

- If possible, use mosquito repellents and rest under mosquito net to prevent bites.

- Look and eliminate any possible mosquito breeding places.

What should not be done ?

- Do not take NSAIDs and antibiotics are not required

- Do not take injection or get a massage

Most importantly, advise them to be alert to the possible warning signs and immediately seek for
medical care.
 Lab investigations of this patient is as follows :

Full blood count result

Description Result Normal Range Interpretation

White blood count 5.2 4- 10 x 10^9 All within normal
Hemoglobin 13.1 12- 16 range.
Hematocrit 40 40
Platelets 245 150- 410 x 10^9

Dengue Rapid Combo Test : Positive for NS1

ECG : Sinus tachycardia

Chest x-ray : Normal

Blood urea and serum electrolyte

Urea 2.6 mmol/l 2.8-7.2 Low

Sodium 135 133-145 The rest are within
Potassium 3.6 3.5-5.1 normal range.
Chloride 102 96-108
Creatinine 47 45-84

Venous Blood Gas

Ph 7.37 7.35- 7.45 Normal

Partial pressure of co2 38.2 35-45 Normal
Partial pressure of o2 43 80-100 Critical Low
Oxygen saturation 74 95-98 Low
Bicarbonate 21.4 22-26 Low
Base excess -3.0 Normal

Liver function test

Total protein 70 57-80

Albumin 43 35-52
Globulin 27 All within normal
A/g ratio 1.6 range.
ALP 85 47-162
ALT 14 <45
Bilirubin total 19.6 5-21

Coagulation Screen

Prothrombin Time : 14.6 s ( Normal)

Activated partial thromboplastin time : 32.9 s ( Normal)

Serum lactate: High ( result : 2.62 mmol/L) Normal Range : 0.50-2.20 mmol/L