CASE PROTOCOL

Our patient is Kristine de Guzman, 25 year old female who lives in San Jose
del Monte Bulacan, admitted last January 9, 2010 due to fever. History started 4
days prior to admission when she started to have undocumented fever, no other
accompanying symptoms noted. 2 days prior to admission, fever was now
accompanied by vomiting and body malaise prompting her to seek consult. CBC
was done and was suggestive of dengue, she was then immediately advised
admission. She was initially admitted at a local hospital but due to unavailability of
platelet concentrate, they decided to transfer to our institution, hence admission.
At the emergency room, she was conscious, coherent, not in cardio
respiratory distress, BP was 90/60, HR 86bpm, RR 22cpm and T of 38.6. She had
symmetrical chest expansion and crackles were noted on both lower lung fields. She
was hooked to PLR 1L at 30 gtts/min. She was also given Plasil 1amp/IV and
Paracetamol 1amp/IV. SP02 was 91%, patient was hooked to O2 via nasal cannula
at 3lpm. She refused insertion of foley catheter. CBC showed hgb 154 hct 0.46 wbc
4.0 seg 73 lymphocytes 19 platelet 23. Urinalysis showed 2-3 pus/ hpf, 7-12 rbc/hpf,
sq cell was ++. PT 18.0 NC 14.6 INR 1.28 PA 72.4% APTT was elevated at 73.1. Na,
K and creatinine were normal. SGPT was elevated at 115 U/L. Blood streaked urine
was noted. She was transfused with 6 units platelet concentrate and 4 units fresh
frozen plasma. CXR revealed bilateral pulmonary congestion, bilateral pleural
effusion more on the right. They were advised ICU admission but opted to be
admitted at a regular ward, consequences were fully explained and understood. She
was started with Voluven 500cc, fast drip at 200cc. BP was now 130/90 with strong
pulses. Patient was noted to be tachypneic and dyspneic, 02 per NC was increased
to 4lpm. Lasix 20mg/IV was given.
At the ward, BP was 130/90 HR 90bpm RR 30cpm.
Another dose of Lasix 20mg/IV was given. 20 meqs KCL was incorporated to IVF.
Repeat HHP was 133, 0.46, 21 respectively. Patient was noted to be in respiratory
distress RR of 30-40 sec. Another dose of Lasix was given, IVF rate was decreased
and nebulization was given. Repeat HHP and APTT at PM was 146, 0.412, 15, 67.2
sec. Sp02 at 5lpm was 89-92%, O2 was increased to 6lpm.
1/10 On the second hospital day, BP was
90/60 HR 90s and still tachypneic at 30-40’s. Still with bilateral crackels on both
lungs. Nasal cannula was shifted to face mask at 10lpm, IVF rate was further
decreased to 10 gtts/min and Lasix 20mg/IV was given. Urine output was good
every after Lasix. Kalium durule was started. Repeat K was normal. Another dose of
Lasix was given. Repeat plt count was 11. Patient was placed on NPO. Standy
intubation was ordered, suggested CPAP. Patient still refused foley catheter
insertion. Another dose of lasix 20mg/IV was given.
1/11 On the 3rd hospital day repeat CBC w/ platelet showed hgb 121
hct 0.34 wbc 6.1 seg 50 lymph 44, platelet 18. She was placed on soft diet, Co-
amoxyclav and nebulization q8 were started. Still tachypneic at 30s cpm, febrile
and dry, 100cc fast drip of IVF was run. Fever was now high grade, Co-amox was
shifted to Tazocin 4.5 g/IV q8. Repeat CXR showed marked increase in the amount
of fluid in the right hemithorax. There was also interval progression of the bilateral
pulmonary congestion now bordering on edema. During the night, patient was
tachypneic at 40’s febrile at 39, Sp02 at 6lpm/FM was 89-90%, placed again on
NPO, FM was shifted to 100% NRM, lasix 20mg/IV was also given. Paracetamol/IV
was given q4. Patient still refused foley cath insertion. Tazocin IV was increased to
q6. Repeat platelet was 40.
1/12 On the 4th hospital day, repeat plt showed 67 . Patient still
tachypneic but more comfortable. Instructed to have sips of water. Pantoloc IV was
shifted to Omeprazole20mg/tab BID. Started on soft diet by afternoon. Lysis of
fever. 1/13 On the 5th
hospital day, 02 NRM was shifted to FM at 8lpm, Tazocin was decreased to q8.
Repeat platelet was 59, Still with crackles. Lasix 20mg/IV was given. Patient was
placed back on regular diet. Repeat platelet was 76
1/14 On the 6 hospital day, patient now is
more comfortable, repeat platelet count was 76. 02 was decreased to 4lpm/ NC.
Omeprazole and nebulization were discontinued. 1/15 On the
th
7 hospital day, hgb was 103, hct 0.299, wbc 5.9 platelet 111. Another dose of Lasix
20mg was given. Diamide K, ½ tab BID was started. Due to the persistence of fever
despite the started tazocin, Azithromycin was started. Repeat chest xray showed
interval regression of the bilateral pulmonary congestion and edema with decrease
in the amount of fluid in the right hemithorax. 1/16 No recurrence
of fever. Paracetamol was discontinued. 1/17
Oxygen supplementation was discontinued. Azithromycin was completed for 3 days.
1/19 Repeat chest xray showed normal result. Tazocin IV was shited to
Co-amoxyclav 625 mg/tab BID for 1 more week. Patient was sent home.