Patient information which did not manage to alleviate her symptoms

and on that night, she experienced facial and body

Name : Nabilah bt azlan , 18 year old malay girl
single, stays at rusila, Marang and works as a
waitress at Pasir Panjang
DOA : 24/1/2015 ( 4 days ago)
itchiness although there were no visible rashes or
any skin lesions. Her mother noticed that he child
looked very ill and appeared drowsy which then
prompt her to the patient to the emergency
department at HSNZ.

DOC : 24/1/2015( on the same day) Systemic Review: ( is unremarkable)

Chief complaint : Ptient came in due to headache 1) General: was fever, lethargy and loss of
for 2 days and fever on the day of admission. appetite but no weight changes

HOPI : 2) Cardiovascular system: absence of chest

pain, palpitations, orthopnea, and
Patient was apparently well until 2 days ago, when
she developed a very bad headache which was paroxysmal nocturnal dyspnea
sudden on onset, episodic, each lasting a few 3) Respiratory system: presence of coryzal
minutes with a pain 4 to 5, on bilateral sides ,was
symptoms and productive cough, no
pulsatile in nature. She tried to relieve the pain by
taking panadol which managed to subside the pain hemptysis
for the day. The head ache was also accompanied 4) Nervous system: Presence of headache,but
by lethargy, she found that she not have the energy
no syncopal attacks, seizure, blurring of
to carried out her daily activities as usual and was
not able to go to work that day. The next day the vision, weakness or numbness of the
headache and lethargic feeling still persisted, her extremities
headache however seem to have gotten worse with
a pain score of 8 and this time around she also felt
5) Urinary system: absence of dysuria,
pain on eye movement. Around evening she polyuria,nocturia and frequency
developed a sudden high grade fever at 39 degree 6) Gastrointestinal system: no indigestion,
measured at home with no chills and rigor, it was
continuous in pattern and was associated with nausea and vomiting or change in bowel
coryzal symptoms, productive cough with habits
yellowish sputum with no blood stains, generalized 7) Musculoskeletal system: presence of
body pain esp at her back and loss of appetite.
Otherwise,patient denied having nausea, vomiting, musche ache but no bone and joint pain
diaarhea, shortness of breath, joint pain, abdominal
pain or any bleeding tendencies. She however
mentioned that there were recent fogging at the
place where she works but other than that there is
no hx of travelling or involment in any recreational
activity like swimming, or jungle trekking or any
having any TB contact. Her parents then brought
her to the pharmacy and there they gave her
panadol, cough mixture and flu medicine, all of
Physical examination

Nabilah is a small built girl . She was alert and

conscious, was lying on the bed. She was not in any
respiratory distress during clerking however she
appeared to be very lethargic and slightly drowsy.
There were canula on the dorsum of each hand
which was connected to drip bags.

Vital signs

Blood pressure :84/51 mm hg

Pulse rate :147 beats per minute, low volume and
regular rhytm

Temperature:39.2

Respiratory rate : 18 breaths per minute

Pain score :0

General Observation:

Hands : Slighlty pale, cold with no cyanosis and crt

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 Ln enlargement.

Trachea was centrally located.

Lower limbs : there were no pitting edema

Summary

Nabilah, 18 year old girl with hx of being in a

dengue prone area came in with worsening
headache and lethargic for 2 days and continuous
high grade fever on the day of admission which
manifested with 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

Differential diagnosis

1) Malaria

2) Leptospirosis

3) Tuberculosis

Investigation

1) Full blood count

2) Blood urea and serum electrolyte/ serum

creatinine

3) Arterial blood Gas

4) lactate level

5) liver function test

6) Dengue combs test

7) chest x-ray

8) ECG

9) malaria test

Management
Full blood count result :

ecg : sinus tachycardia

Chest x-ray : Normal

Blood urea and serum electrolyte:

Urea 2.6 mmol/l ( 2.8-7.2

LOW)
Sodium 135 133-145
Potassium 3.6 3.5-5.1
Chloride 102 96-108
Creatinine 47 45-84

Arterial blood gas :

ph 7.37 7.35- 7.45

partial pressure 38.2 35-45
of co2
partial pressure 43 ( CRITICAL 80-100
of o2 LOW)
ooxygen 74( LOW) 95-98
saturation
bicarbonate 21.4( LOW) 22-26
base excess -3.0

Liver function test:

total protein 70 57-80

albumin 43 35-52
globulin 27
a/g ratio 1.6
ALP 85 47-162
ALT 14 <45
bilirubin total 19.6 5-21

Prothrombin time and activated prothrombin time :

PT : 14.6

APTT : 32.9

Lactate: High ( result : 2.62 mmol/L) -0.50-2.20