OPD Case 1

Dr Amilia Hazreena Hamidon

KK Greentown
 26/6/12 Klinik 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

Fever ? Cause

Treatment:

Paracetamol

Cefaclor 375mg bd

Q1: What is your comment on the case

management?
Answer Q1: Page 17

A Stepwise approach on outpatient

management of dengue infection is important

Step 1: Overall assessment Not to forget

1. History assessment of

2. Physical examination- not done co-morbidities,eg
capillary sugar etc

3. Investigations - ?UFEME / FBC

Step 2 : Diagnosis, disease staging and severity

assessment

Step 3 : Plan of management

 27/6/12 (Day 4 of fever) at Klinik
Kesihatan

Patient came back the next day, still complaining of
fever with lethargy, diarrhea, vomiting and epigastric
pain.

T=38.5⁰C, BP 110/65, PR 100/min, hydration fair,
Abd: soft, mild epigastric tenderness

Diagnosis: Acute Gastroenteritis with gastritis

Differential Diagnosis Dengue Fever

Hb 10.3, HCT 41.5% Platelet count 120

To review the next day with repeat FBC

Q2: a) What are the warning signs?

b) Would you have admitted this patient?
Answer Q2(a):
Page 18
Answer Q2(b):
CRITERIA FOR HOSPITAL REFERRAL /
ADMISSION
Page 19
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. DM, IHD,
coagulopathies, morbid obesity, renal failure,
chronic liver disease
• Elderly (>65 years old)
• Pregnancy
• Social factors that limit follow-up e.g. living far
from health facility, no transport etc

4. Laboratory Criteria:
• Rising HCT accompanied by reducing platelet
count
28/6/12 (Day 5 of fever)

Brought to KK at 12:05pm by ambulance call

Seen by MO

Fever 5 days

still had diarrhea and vomiting

Headache and joint pain

Epigastric pain for 2 days

Dark sticky stool 2 days

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 to the hospital

Referred to hospital and accompanied by
JM

Q3. What could have been done by the doctor at K

Kesihatan ?
Answer Q3:
Page 19

The BP, Pulse monitoring must be continued while in

the ambulance and patient must be accompanied by MO/MA