GM Elog Case-6
RISHIK
R NO 37
A 70yr OLD MALE WITH DENGUE SHOCK SYNDROME
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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
Patient was apparently asymptomatic 1 week back after which he started Binge drinking for 2 days and then he developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor.
After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to loacl hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000.
He Wasn't responding for commands since yesterday evening and became unconscious since yesterday night and he was brought here to our hospital today morning.
Patient is a known case of Chronic Alcoholism since 30 years and increased his intensity since last 3 years.
smoking since 20 yrs, average 2 beedi per day
At the Time of Presentation
BP: 90/60mmhg
PR: 102bpm
GRBS: 34mg/dl
Temperature: 99°F
RR: 36cpm
SpO2: 85% with 4 Liters of O2
Severe Thrombocytopenia with Bleeding Manifestations (Epistaxis)
Patient was initially given in Casualty:
1. 25% Dextrose for Hypoglycemia
2. IVF. NS Bolus 1 Liter
On Examination
Patient was Unconscious
Icterus present
Patient was in gasping state, In view of falling saturation and risk of aspiration and low GCS patient was Intubated and kept on Mechanical Ventilation.
Post Intubation Xray
 |
| Post Intubation Xray |
Provisional diagnosis:
Dengue shock syndrome
(??Dengue encephalitis)
With hepatitis SECONDARY to Dengue? Alcohol??
With Pre renal AKI
Lab Investigations:
# 17/08/2021
 |
| ABG Post Intubation |
 |
# 18/08/2021
#19/08/2021
Treatment:
DAY 1
1. IVF NS,RL @150ML/HR
2. INJ. AUGUMENTIN 1.2GM IV/BD
3. INJ. PANTOP 40MG IV/OD
4. INJ. TRANEXA 500MG IV STAT
5. INJ. VIT K IV/OD
6. RT FEEDS 200ML FREE WATER - 1 HRLY, 200ML MILK PROTEIN POWDER - 2ND HRLY
7. SYRUP. LACTUOSE 15ML/BD
8. 1 UNIT SDP TRANSFUSION
9. BP/PR/ TEMP MONITORING 2ND HRLY
10.ABG 8TH HRLY
11. DAILY PCV, PLATELETS MONITORING
DAY 2
1. INJ. AUGUMENTIN 1.2GM IV/BD
2. INJ. PANTOP 40MG IV/OD
3. INJ. HYDROCORT 100MG IV BD
4. INJ. THIAMINE 200MG IV IN 100ML NS IV/BD
5. IVF NS, RL @100ML/HR
6. SYRUP. LACTULOSE 10ML PO/BD
7. RT FEEDS 300ML FREE WATER - 1 HRLY, 200ML MILK PROTEIN POWDER - 2ND HRLY
8. DAILY PCV, PLATELETS MONITORING
9. ABG 12TH HRLY
10. BP/PR/TEMP MONITORING 1HRLY
11. ENEMA SOAP WATER/PROCTOLYTICS
12. NEBULIZATION WITH MUCOMIST, BUDECORT 6TH HRLY
13. NO IM INJECTION
19/08/2021
ON 19/08/2021 @ 06:50AM
In view of falling saturation and BP not recordable &pulselessness, CPR was initiated
INJ. ADRENALINE was given
@06:50am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@06:55am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:00am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:05am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:10am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:15am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
INSPITE OF OUR EFFORT THE PATIENT COULDNT BE REVIVED &DECLARED DEAD ON
19/08/2021 AT 07:22 AM
DEATH SUMMARY
70YR/M patient was brought to casualty in unconscious state.
Altered sensorium present since 1 day
History of fever since 3 days
outside report shows DENGUE NS1 POSITIVE
History of Pain Abdomen since 3 days
Patient was intubated in view of poor GCS (3/15) and falling saturation
All further Investigations were done &diagnosed with Dengue Shock Syndrome (severe
thrombocytopenia) with AKI with Hepatitis (viral) and treated conservatively.
On 19/08/2021 at 06:50 am, patient was having BP not recordable &pulse not recordable. CPR was
initiated , 6 cycles of CPR was done. despite that patient couldnt be revived &declared dead on
19/08/2021 at 07:22am
IMMEDIATE CAUSE OF DEATH:
DENGUE SHOCK SYNDROME
TYPE 2 RESPIRATORY FAILURE
SEVERE METABOLOIC ACIDOSIS
ANTECEDENT CAUSE OF DEATH:
HYPOXIC ISCHEMIC ENCEPHALOPATHY
ALCOHOL/VIRAL HEPATITS
ACUTE KIDNEY INJURY.
DISCHARGE SUMMARY
Discharge Date
Date: 19/08/2021
Ward: ICU
Unit: 2
Name of Treating Faculty
DR. RAKESH BISWAS [HOD]
DR. ARJUN [ASSIT.P]
DR. AJITH [PGY3]
DR. G. VAMSHI KRISHNA [PGY2]
DR. RISHIK [INTERN]
DR. ACHAL [INTERN]
DR. MANASA [INTERN]
DR. RAVALI [INTERN]
DR. JANCY [INTERN]
DR. RAGHU [INTERN]
Diagnosis
DENGUE SHOCK SYNDROME WITHTYPE 2 RESPIRATORY FAILURE
VIRAL HEPATITIS WITH AKI
HYPOXIC ISCHEMIC ENCEPHALOPATHY
Case History and Clinical Findings
A 70yr old male, agriculture by occupation was brought to casualty in an Unconscious state since
yesterdayPatient was apparently asymptomatic 1 week back after which he started Binge drinking for
2 days and then he developed Fever that last for 3 days and developed Abdominal pain Burning type
both for which he was treated by local Doctor.After that he developed weakness which is gradual in
onset and was unable to stand for which he was admitted to loacl hospital where he was diagnosed
to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000.He
Wasn't responding for commands since yesterday evening and became unconscious since yesterday
night and he was brought here to our hospital today morning.Patient is a known case of Chronic
Alcoholism since 30 years and increased his intensity since last 3 years.smoking since 20 yrs,
average2 beedi per dayAt the Time of PresentationBP: 90/60mmhgPR: 102bpmGRBS:
34mg/dlTemperature: 99°FRR: 36cpmSpO2: 85% with 4 Liters of O2Severe Thrombocytopenia with
Bleeding Manifestations (Epistaxis)CVS: S1, S2 PRESENT RS: BAE PRSENT, B/L CREPTS
HEARD PER ABDOMEN: SOFT, BOWEL SOUNDS HEARDPatient was initially given in Casualty:1.
25% Dextrose for Hypoglycemia2. IVF. NS Bolus 1 LiterPatient was in gasping state, In view of falling
saturation and risk of aspiration and low GCS patient was Intubated and kept on Mechanical
Ventilation.Provisional diagnosis:Dengue shock syndrome(??Dengue encephalitis)With hepatitis
SECONDARY to Dengue? Alcohol??With Pre renal AKI
Investigation
17/08/2021
RBS - 155MG/DL
BLOOD GROUPING &TYPING - O POSITIVE
PT - 16 SEC
INR - 1.11
APTT - 32 SEC
BT - 2 MIN 00 SEC
CT - 4 MIN 30 SEC
HEMOGRAM
HB - 10.6 GM/DL
TOTAL COUNT - 13800 CELLS/CUMM
NEUTROPHILS - 72%
LYMPHOCYTES - 18%
EOSINOPHILS - 02%
MONOCYTES - 08%
BASOPHILS - 00%
PCV - 30.1 VOL%
MCV - 88.5 FL
MCH - 31.2 PG
MCHC - 35.2%
RDW-CV - 18.0%
RDW-SD - 58.0 FL
RBC COUNT - 3.40 MILLIONS/ CUMM
PLATELET COUNT - 25000 LAKHS/CUMM
SMEAR: NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS AND
THROMBOCYTOPENIA
18/08/2021
HEMOGRAM
HB - 9.2 GM/DL
TOTAL COUNT - 12300 CELLS/CUMM
NEUTROPHILS - 82%
LYMPHOCYTES - 10%
EOSINOPHILS - 01%
MONOCYTES - 07%
BASOPHILS - 00%
PCV - 25.6 VOL%
MCV - 88.3 FL
MCH - 31.7 PG
MCHC - 35.9%
RDW-CV - 18.2%
RDW-SD - 58.8 FL
RBC COUNT - 2.90 MILLIONS/ CUMM
PLATELET COUNT - 1.05 LAKHS/CUMM
SMEAR: NORMOCYTIC NORMOCHROMIC BLOOD PICTURE WITH NEYTROPHILIC
LEUCOCYTOSIS AND MILD THROMBOCYTOPENIA
SARS-COV-2
Qualitative PCR 17-
08-2021 12:03:PM
Negative
COMPLETE URINE EXAMINATION (CUE) 17-08-2021 01:07:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-6
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
ABG 17-08-2021 01:07:PM
PH 7.30
PCO2 24.9
PO2 61.8
HCO3 11.9
St.HCO3 14.5
BEB -12.9
BEecf -13.3
TCO2 24.7
O2 Sat 76.2
O2 Count 7.4
LIVER FUNCTION TEST (LFT) 17-08-2021 01:07:PM
Total Bilurubin 6.89 mg/dl 1-0 mg/dl
Direct Bilurubin 2.10 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 488 IU/L 35-0 IU/L
SGPT(ALT) 158 IU/L 45-0 IU/L
ALKALINE
PHOSPHATE
310 IU/L 119-56 IU/L
TOTAL PROTEINS 5.1 gm/dl 8.3-6.4 gm/dl
ALBUMIN 1.89 gm/dl 4.6-3.2 gm/dl
A/G RATIO 0.59
RFT 17-08-2021 01:07:PM
UREA 113 mg/dl 50-17 mg/dl
CREATININE 3.2 mg/dl 1.3-0.8 mg/dl
URIC ACID 9.8 mg/dl 7.2-3.5 mg/dl
CALCIUM 10.2 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 5.0 mg/dl 4.5-2.5 mg/dl
SODIUM 140 mEq/L 145-136 mEq/L
POTASSIUM 3.5 mEq/L 5.1-3.5 mEq/L
CHLORIDE 104 mEq/L 98-107 mEq/L
Anti HCV Antibodies
- RAPID 17-08-2021
01:07:PM
Non Reactive Kit
Name:Life Band
HBsAg-RAPID 17-
08-2021 01:07:PM
Negative Kit Name:
Abon
ABG 17-08-2021 11:08:PM
PH 7.20
PCO2 38.3
PO2 83.8
HCO3 14.4
St.HCO3 14.6
BEB -12.5
BEecf -12.0
TCO2 31.1
O2 Sat 90.9
O2 Count 14.1
RFT 18-08-2021 02:35:AM
UREA 100 mg/dl 50-17 mg/dl
CREATININE 2.5 mg/dl 1.3-0.8 mg/dl
URIC ACID 8.4 mg/dl 7.2-3.5 mg/dl
CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 5.3 mg/dl 4.5-2.5 mg/dl
SODIUM 142 mEq/L 145-136 mEq/L
POTASSIUM 3.0 mEq/L 5.1-3.5 mEq/L
CHLORIDE 102 mEq/L 98-107 mEq/L
ABG 18-08-2021 02:10:PM
PH 7.25
PCO2 46.0
PO2 99.2
HCO3 19.5
St.HCO3 18.7
BEB -7.0
BEecf -6.5
TCO2 41.5
O2 Sat 95.7
O2 Count 14.8
COMPLETE BLOOD PICTURE (CBP) 18-08-2021 09:36:PM
HAEMOGLOBIN 7.5 gm/dl 17.0-13.0 gm/dl
TOTAL COUNT 2800 cells/cumm 10000-4000
cells/cumm
NEUTROPHILS 75 % 80-40 %
LYMPHOCYTES 20 % 40-20 %
EOSINOPHILS 01 % 6-1 %
MONOCYTES 04 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 90,000/cumm
SMEAR Pancytopenia
ABG 18-08-2021 09:36:PM
PH 7.13
PCO2 54.6
PO2 60.6
HCO3 17.7
St.HCO3 15.4
BEB -11.3
BEecf -9.8
TCO2 38.4
O2 Sat 82.1
O2 Count 14.4
ABG 19-08-2021 12:01:AM
PH 6.89
PCO2 56.8
PO2 37.4
HCO3 10.3
St.HCO3 8.1
BEB -21.2
BEecf -20.2
TCO2 25.7
O2 Sat 35.7
O2 Count 3.7
Treatment Given(Enter only Generic Name)
DAY 1
1. IVF NS,RL @150ML/HR
2. INJ. AUGUMENTIN 1.2GM IV/BD
3. INJ. PANTOP 40MG IV/OD
4. INJ. TRANEXA 500MG IV STAT
5. INJ. VIT K IV/OD
6. RT FEEDS 200ML FREE WATER - 1 HRLY, 200ML MILK PROTEIN POWDER - 2ND HRLY
7. SYRUP. LACTUOSE 15ML/BD
8. 1 UNIT SDP TRANSFUSION
9. BP/PR/ TEMP MONITORING 2ND HRLY
10.ABG 8TH HRLY
11. DAILY PCV, PLATELETS MONITORING
DAY 2
1. INJ. AUGUMENTIN 1.2GM IV/BD
2. INJ. PANTOP 40MG IV/OD
3. INJ. HYDROCORT 100MG IV BD
4. INJ. THIAMINE 200MG IV IN 100ML NS IV/BD
5. IVF NS, RL @100ML/HR
6. SYRUP. LACTULOSE 10ML PO/BD
7. RT FEEDS 300ML FREE WATER - 1 HRLY, 200ML MILK PROTEIN POWDER - 2ND HRLY
8. DAILY PCV, PLATELETS MONITORING
9. ABG 12TH HRLY
10. BP/PR/TEMP MONITORING 1HRLY
11. ENEMA SOAP WATER/PROCTOLYTICS
12. NEBULIZATION WITH MUCOMIST, BUDECORT 6TH HRLY
13. NO IM INJECTION
19/08/2021
ON 19/08/2021 @ 06:50AM
In view of falling saturation and BP not recordable &pulselessness, CPR was initiated
INJ. ADRENALINE was given
@06:50am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@06:55am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:00am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:05am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:10am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
@07:15am BP,PR not Recordable - INJ.ADRENALINE 1gm IV/STAT
INSPITE OF OUR EFFORT THE PATIENT COULDNT BE REVIVED &DECLARED DEAD ON
19/08/2021 AT 07:22 AM
DEATH SUMMARY
70YR/M patient was brought to casualty in unconscious state.
Altered sensorium present since 1 day
History of fever since 3 days
outside report shows DENGUE NS1 POSITIVE
History of Pain Abdomen since 3 days
Patient was intubated in view of poor GCS (3/15) and falling saturation
All further Investigations were done &diagnosed with Dengue Shock Syndrome (severe
thrombocytopenia) with AKI with Hepatitis (viral) and treated conservatively.
On 19/08/2021 at 06:50 am, patient was having BP not recordable &pulse not recordable. CPR was
initiated , 6 cycles of CPR was done. despite that patient couldnt be revived &declared dead on
19/08/2021 at 07:22am
IMMEDIATE CAUSE OF DEATH:
DENGUE SHOCK SYNDROME
TYPE 2 RESPIRATORY FAILURE
SEVERE METABOLOIC ACIDOSIS
ANTECEDENT CAUSE OF DEATH:
HYPOXIC ISCHEMIC ENCEPHALOPATHY
ALCOHOL/VIRAL HEPATITS
ACUTE KIDNEY INJURY.
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