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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

joint pain. vomiting. productive cough with yellowish sputum. muscle pain. abdominal pain. Before coming to the emergency department. Otherwise. around evening she developed high grade fever around 39 degree which was continuous in pattern with no chills or rigors. flu medication and cough syrup was unable to alleviate her symptoms. generalized body pain especially at her back. . facial and body itchiness and loss of appetite. patient took over the counter drugs like panadol. rashes or any bleeding tendencies. diarrhoea. 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.Patient Information Name : Nabilah bt azlan Age : 18 year old malay girl Address : Rusila. It was associated with coryzal symptoms. or jungle trekking or any having any TB contact. retro-orbital pain. shortness of breath. patient denied having nausea. 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. 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.

lethargy and loss of appetite but no weight changes Cardiovascular system : No chest pain. seizure or change in mental status Urinary system : No hematuria. shortness of breath. dysuria or oliguria Gastrointestinal system : No nausea. 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. take alcohol or recreational drugs. Social History Patient is working at Pasir Panjang ( a dengue prone are) but otherwise she does not smoke.Systemic Review General : Presence of fever. 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. vomiting. no hemoptysis Central Nervous system : Presence of headache but no loss of consciousness . orthopnea or paroxysmal nocturnal dyspnoea Respiratory system : Presence of coryzal symptoms and productive cough. Drug and Allergy History Other than the drugs mentioned. . Family History Both her parents and two siblings are well and there is no family history of chronic or inherited illnesses in the family.

Percussion: Was resonant and shifting dullness was negative. On the arms there were no rashes. Respiratory System Examination Inspection: Chest moves symmetrically with respiration and there is no signs of laboured breathing. low volume. Palpation : Trachea is centrally located. The left one connected to a drip bag. moves with respiration and umbilicus is centrally located and inverted. Percussion : Equally resonant on both sides.9kg m² Temperature : 39◦C Pain score : 0 General Observation: Hands : Slighlty pale. .Physical Examination Nabilah is a small built girl. Face : No conjuctival pallor. Trachea was centrally located. She appeared drowsy and was lying on her bed. cold with no cyanosis and capillary refill time was 2 seconds. Vocal resonance is normal. regular Height : 1. no scars. Lower limbs : There were no pitting edema Abdominal Examination Inspection : Abdomen is not distended. Chest expansion is equal and vocal fremitus is normal. Palpation: Soft and non-tender. her lips were dry otherwise there was no central cyanosis. Auscultation : Normal air entry on both sides and there is no added sounds like crepitations or wheeze. Vital Signs Blood Pressure : 84/51 mmHg Weight : 42 Kg Pulse rate : 147 beats per minute. No hepatosplenomegaly and kidneys are not ballotable.53 m² Respiratory rate : 18 breaths per minute Body Mass Index : 17. She was not in any respiratory distress during clerking and there was cannula on the dorsum of each hand. Auscultation : Normal bowel sounds were heard. 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.

Otherwise the physical examination was unremarkable. Provisional Diagnosis: Dengue fever in decompensated shock Supporting Points : . mid-clavicular line. febrile. 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.Cardiovascular System Inspection : No chest deformity or scars. tacycardia ( Signs of decompensated shock) Differential Diagnosis : 1) Septic shock due to pneumonia Supporting points : . Higher cortical function and sensory function is intact.coryzal symptoms and cough ( Signs of dengue) . Central Nervous System No abnormal posture or fasiculations. back ache. Auscultation : Normal first and second heart sound heard. her lips were dry and she appeared drowsy. lethargy and loss of appetite -Cold peripheries.headache. muscle ache. No heaves or thrills.Cold peripheries. power and reflexes are normal on both extremities. productive cough with yellowish sputum. low peripheral pulse. Palpation : Apex is felt at 5th intercostal space. loss of appetite and facial and body itchiness. Summary Nabilah. coryzal symptoms. productive cough.Febrile. tacycardia ( Signs of late septic shock) . prolonged capillary refill time. coryzal symptoms.lethargy. febrile with tachycardia and low pulse volume along with pale and cold peripheries and capillary refill time was 2 seconds. joint ache. Tone. low peripheral pulse. hypotension. lethargy. prolonged capillary refill time. generalised body pain.From dengue prone area. hypotension. patient was found to be hypotensive. On physical examination.

2) Dengue Rapid Combo test 3) Blood urea and serum electrolyte/ Serum creatinine.To detect metabolic acidosis in this patient. Some of the tests are mentioned above. 7) Nearest district health office should be informed. 7) Chest x-ray. 4) Venous blood gas . oxygen saturation. headache. lethargy and loss of appetite Investigations 1) Full blood count. breathing and circulatory status must be done. 5) Serum lactate. respiratory rate. muscle pain.To detect any white blood count. 2) Clinical assessment of the airway.2) Malaria Supporting points : .To detect any heart abnormalities. platelet and hematocrit abnormalities. 5) Vital signs and ongoing fluid losses should be monitored strictly.Took look for any dengue related complications. presence of any warning sign. .Febrile. the patient must be started on appropriate fluid therapy either orally or intravenously. neurological status. Parameters to be monitored : Appetite. oral intake. blood pressure. 8) Electrocardiogram ( ECG). electrolyte imbalance or kidney injury. 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. 4) If admission is required. 6) Liver function test. 3) Necessary lab test should be done. pulse pressure.To look for pleural effusion and heart abnormalities.To assess the degree of inadequate tissue perfusion.To detect fluid and electrolyte abnormalities and signs of kidney injury due to shock. Management At the emergency department 1) Do triage checklist at registration counter and vital signs must be taken.

3) If admission is indicated .Daily follow up is necessary especially from day 3 of illness onwards until the patient becomes afebrile for at least 24.Patient and their caretakers should be advised on how to take care of the patient at home. use mosquito repellents and rest under mosquito net to prevent bites.Take paracetamol ( not more than 4 gram per day) .Outpatient management 1) Dengue assessment checklist must be filled.If possible.Adequate bed rest and fluid intake ( more than 8 glasses or 2 litres) .Do not take NSAIDs and antibiotics are not required .The receiving hospital/ emergency department should be informed before transfer.48 hours without antipyretics . What should be done? . 2) The nearest district health office should notified followed by disease notification form.Do not take injection or get a massage Most importantly. 4) If admission is not indicated . What should not be done ? . advise them to be alert to the possible warning signs and immediately seek for medical care. .The patient should be stabilized before transfer . .Tepid sponging .Look and eliminate any possible mosquito breeding places.

6 s ( Normal) Activated partial thromboplastin time : 32.7.2 4.10 x 10^9 All within normal Hemoglobin 13.6 range.4 22-26 Low Base excess -3.8-7.6 mmol/l 2.1 normal range.20 mmol/L .50-2.37 7.16 range.62 mmol/L) Normal Range : 0.1 12. Lab investigations of this patient is as follows : Full blood count result Description Result Normal Range Interpretation White blood count 5. Chloride 102 96-108 Creatinine 47 45-84 Venous Blood Gas Ph 7.2 Low Sodium 135 133-145 The rest are within Potassium 3.6 5-21 Coagulation Screen Prothrombin Time : 14. ALP 85 47-162 ALT 14 <45 Bilirubin total 19.35.410 x 10^9 Dengue Rapid Combo Test : Positive for NS1 ECG : Sinus tachycardia Chest x-ray : Normal Blood urea and serum electrolyte Urea 2.0 Normal Liver function test Total protein 70 57-80 Albumin 43 35-52 Globulin 27 All within normal A/g ratio 1.6 3.9 s ( Normal) Serum lactate: High ( result : 2.45 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 21.5-5. Hematocrit 40 40 Platelets 245 150.