15/1/23

1500h ED CLERKING

27 / M / , NKMI, Chronic smoker

C/o:
- abdominal pain X1/7
- mainly @ epigastric region
- started suddenly @ 3pm today
- pricking in nature , persistent
- 0 radiation
- not relieved by PCM taken @ 1.30pm today

A/w: + diarrhea X1/7

- 3 times since today morning
- loose stool , unsure color & whether has blood in feces
+ lethargy - on MC X3/7
due tofever + URTI : Rx as bacterial URTI by GP,
completed Abx X3/7
+ h/o fever X3/7 started on Thursday (12/1/2023) @ 9am
- fever resolved since today noon @ ~12noon
+ u/o: last voiding @ 6am today
oral intake; taken only ~ 250cc plain water since morning,
poor appetite

Otherwise , no nausea / vomiting

no spontaneous mucosal bleeding / rashes
no SOB / chest pain / cough
no recent travelling / jungle trekking

+ stay in dengue prone area - h/o fogging last week

Allergy hx; NKDA / no h/o food allergy

PMHx; Nil
PSHx; Nil

cracked lips
O/e: alert, GCS 15/15, dehydrated dry, coated tongue

CVS : DRNM, 0
muffled heart sound
BP: 129/76
Lungs PR : 102 bpm
Clear T0 : 37oC
A/e good & equal SPO2: 97% RA
0
creps / rhonchi

1
 PA
Tender @ epigastric
0
guarding

Liver not
palpable
Ix: FBC
- HCT: 45
- Hb: 12.3
- Plt: 140
- T WC: 3.5

Rapid combo test:

Not available

: DF Day 4 of illness (PT; 12/1/23 @ 9am) in critical

phase 5 hours (since 12 noon today) with warning
signs;
lethargy, abdominal pain , multiple diarrhea

Plan:

l Rahim
ad Bin Abdu
Dr. Muhamm ah UD41
ubatan Siswaz rp
Pegawai Per
atan Medico
Pusat Perub 4321
MMC No: 5

2
 16/1/23
0010h Admission review

27 / M / , NKMI, Chronic smoker

BMI 21, BW; 60kg

DF Day 4 of illness (PT; 12/1/23 @ 9am) in critical phase 12

hours with ;
- resolved compensated dengue shock - given graded bolus @ED
- resolved warning sign; lethargy, abd pain , diarrhea
- NSI +ve @ ED, dengue serology sent
- notification & dengue registration sent

Plan (S/B Specialist)

1) Encourage orally as tolerated
Ix
2) Continue IVD 1.5cc/kg/h
FBC tds 3) For TDS r/v by MO

BUSE OD 4) Strict I/O chart, aim u/o > 0.5cc/kg/h
5) FBC TDS, daily BUSE
6) Trace dengue serology
7) KIV refer surgical if abd pain recurs

l Rahim
Dr. Muhammad Bin Abdu
zah UD41
Pegawai Perubatan Siswa
Pusat Perubatan Me dic orp
MMC No: 54321

3
16/1/23
0700h AM review

27 / M / , NKMI, Chronic smoker

BMI 21, BW; 60kg

DF Day 4 of illness (PT; 12/1/23 @ 9am) in critical phase 19

hours with ;
- resolved compensated dengue shock - given graded bolus @ED
- resolved warning sign; lethargy, abd pain , diarrhea
- NSI +ve @ ED, dengue notification sent
- on IVD 1.5cc/kg/h

Currently, abd pain resolved , current pain score 0

oral intake much improved;
- taken 500cc since admission last midnight
last PU 5am - 500cc
Clear urine

Otherwise , no vomiting / diarrhea ,

denies lethargy / dizziness,
no spontaneous mucosal bleeding,
no SOB / chest pain

O/e:
alert, GCS 15/15, pink , comfortable
hydration fair; moist tongue
V/S stable since admission

BP: normal range , no narrowing pulse pressure
PR : normal range , no episodes of tachycardia
T0 : afebrile since admission
SPO2: 98% RA
I/O = +630cc
U/O: 500c/60kg/7h = 1. 2cc/kg/h

FBC
CVS : DRNM, 0
muffled heart sound - HCT: ___
Clear - Hb: ____
Lungs - Plt: ____
equal a/e
- T WC: ____

IgM; -ve
PA: Soft, not tender IgG; +ve

LFT - N
RP - N

4
 Revised ; Secondary DF, Day 4 of illness in critical phase 19 hours
with resolved compensated shock & warning signs

Plan
Ix 1) Reduce IVD to 1. 2cc/kg/hour
FBC tds 2) Encourage orally
3) W/out warning signs (recurrent abd pain , evidence
of leaking, mucosal bleeding)
4) Inform if BP < 100/70, narrowing pulse pressure
5) Continue FBC TDS

Dr. Muhammad Bin Abdul Rahim

Pegawai Perubatan Siswazah UD41
Pusat Perubatan Medicorp
MMC No: 54321