Accident And Emergency Posting Case Write Up

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 m²

Respiratory rate : 18 breaths per minute

Body Mass Index : 17.9kg m²

Temperature : 39◦C 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 White blood count Hemoglobin Hematocrit Platelets

Result 5.2 13.1 40 245

Normal Range 4- 10 x 10^9 12- 16 40 150- 410 x 10^9

Interpretation All within normal range.

Dengue Rapid Combo Test : Positive for NS1 ECG : Sinus tachycardia Chest x-ray : Normal Blood urea and serum electrolyte Urea Sodium Potassium Chloride Creatinine

2.6 mmol/l 135 3.6 102 47

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

Low The rest are within normal range.

Venous Blood Gas Ph Partial pressure of co2 Partial pressure of o2 Oxygen saturation Bicarbonate Base excess

7.37 38.2 43 74 21.4 -3.0

7.35- 7.45 35-45 80-100 95-98 22-26

Normal Normal Critical Low Low Low Normal

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 All within normal range. 47-162 <45 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