Dr. Nalone Thayaso,Deputy Head of Pediatrics Department

1-2nd March 2018, Pediatrics CME, VTE

Introductory data� Age: 11 years old girl� Job: student� Address : TANGLANG village, SANASOMBOUN

District, CHAMPASAK Province� Admission date: 24/5/2017 time 08:30 am

Chief complaint.�Fever + weakness for 2 weeks.

History of Present Illness.� A child came with persistent fever for 2 weeks, headache and

associated body pain (24/05/2017)� In the first week of fever a child went to Nakharm dispensary,

got some medicine and 2 IV drip fluid ( unknown name of fluid & medication) after that fever subsided.

� On 19/05/2017 a child has got some fever again, and they went to see health center and got 2 bags of IV drip fluid (500 ml).

� On the night 23/05/17 a child has got 4 times melena symptom and 4 times coffee ground vomit (Mother couldn’t assess quantity). Additionally she had epistaxis (small amount), was irritable and presented weekness. And the family brought her to the CHAMPASAK Hospital on 24/05/17( 08h.00).

   Past Medical History.v Personal :

previously healthyNo hospitalization in the pastNo allergyNo medicationFirst child in familyVaccination incomplete (vaccination chart unavailable)

v Family:Father suspected for thalassemia (had blood transfusion )

Physical examination  � Drowsiness, pallor, cold extremities, no edema, lethargy� Skin : capillary refill 4s� HEENT : normal� Vital signs :

ØManual BP : not measuredØPulse : not measure ØBody temperature : 38.5 °C ØBody weight : 23kg

Review of Systems� HEART : tachycardia, no murmur � LUNG : clear bilaterally� ABDOMINAL: Pain on palpitation, no hepato-

splenomegaly � URINARY TRACT: Dysuria � NEURO: normal

Summary of Positive findings� 11 years old girl � Fever last long 2 weeks + weakness� High grade fever, fever intermittent � Melena 4 times and 4 times coffee ground vomit � Epistaxis, weakness and cold extremities� Family history father suspect for thalassemiaØ physical examination:� drowsiness, pale , cold body, lethargy� skin : CRT 4s � Vital sign :

Ø Manual BP : not measureØ Pls : not measure Ø T : 38.5 °C , Ø BW : 23kg, (weigth/age < -3SD)

� Heart : tachycardia� Abdomen : pain on palpation

 Impression� Septic shock ?� Typhoid fever ?� Severe dengue with hypotensive shock ?

Differential diagnosis� Leptospirosis� Rickettsia� Sepsis� GI Bleeding

 Laboratory results � NS1 : positive� Test dengue

ü IgG : negativeü IgM: negative

� Malaria rapid test : negative, Rickettsia test :(-), lepto test :(-)� Widat test : negative� Glucose test : 23mg/dl� Calcium : 9,02 mg\dl� Creatinin: 1,04 mg\dl� SGOT : 5491 U\L� SGPT : 2153U\L� K : 3,90 mmol\l� Na : 134,9 mmol\l� CL : 95 mmol\l

24/05/2017

Time/date

HCT WBC

PLT

BP T Color

CRT

Temp PlsVol

Plsrate

intake symptom urine

24/5/178h30

29 9,57 241 0 38,8 pale 3s cool Notmeasured

Notmeasured

NSS20cc/kgbolus

drowsiness,paleTwo IV dripBlood sugar test: 23mg/dl add: IV 50% glucose 4Amp.

9h00 100/60 38 pale 3s Warm Strong 110 NSS20cc/kgbolus

Abdo pain

9h30 100/69 38,5 pale 2s Warm Strong 110 D5RL3CC/kg

Goodconscious ,abdominalpainBlood sugar: 192mg\dlAdd:Ceftriaxone+metronidazolecimetidine+spamacon

10h30 110/60 38,5 pale 2s Warm Strong 99 D5RL3CC/kg

Abdo pain

11H30 92/60 38,2 pale 2s Warm Strong 105 D5RL3CC/kg

Abdo pain

Time/date

HCT WBC PLT BP BT Col CRT Temp Pls Vol Plsrate

intake symptom urine

13H30 100/60 37 pale 3s Warm Strong 110 D5RL3CC/kg

Abdo pain

15h00 27 7,07 236 80/70 36 pale 3s cool mild 120 Dextran 10cc/kg

Abdo painBlood sugar: 260mg\dl

16h20 88/64 36 pale 3s Cold Strong 100 Dextran10cc/kg

Weakness,abdo pain

17h30 20 6,12 136 100/60 37 pale 2c warm Strong 110 Dextran7cc/kg

Wait for blood

18h30 100/60 37 pale 2c warm Strong 96 Dextran 7cc/kg

Wait for blood

19h30 100/60 37 pale 2c warm Strong 90 Dextran 5cc/kg

Wait for blood

20h30 100/60 37 pale 2c warm Strong 90 Blood430ml33drop/min

transfusion

Time/date

HCT

WBC

PLT BP BT Color CRT Temp

PlsVol

Plsrate

intake symptom urine

21h30 100/60 37 Pale 2s warm Strong 106 ContinuingBlood transfusion

22h30 100/67 37 pale 2s warm Strong 108 ContinuingBlood transfusion

23h30 107/67 37 pale 2s warm Strong 106 Keep vein Dextran 12drop/min

Black stool 20cc

25/5/1700h30

107/79 37,5 pale 2s warm Strong 109 Keep vein Dextran 12drop/min

Abdo pain 6ooml

01h30 92/60 37 pale 2s warm Strong 116 Keep vein Dextran 12drop/min

Black stool 20cc

02h30 38,9 9,3 185 0 36,5 pale 3s cool 0 0 Dextran 10 cc/kg

Black stool 10cc,restless

3h00 0 36,5 pale 3s cool 0 0 Dextran10cc/kg

restless

Time/date

HCT WBC PLT BP Temp Color CRT Temp Pulsevolume

Pulserate

intake symptom urine

3h30 0 36,5 pale 3s cool mild 128 Dextran10cc/kg

restless

4h00 0 36,5 pale 3s cool mild 120 Dextran10cc/kg

sleep

4h30 40 90/72 36,5 pale 3s cool mild 128 Dextran 7cc/kg

sleep

5h00 110/80 36,5 pale 3s warm Strong 118 Dextran5cc/kg

sleep

6h00 27 6,19 122 110/80 36 pale 3s warm Strong 108 Dextran 5cc/kg

total intake 2950ml ,total output 695ml

Fluid  recommended Fluid  received

Maintenance 1560 ml/24hour Total  2950ml

M+5% deficit 2710 ml/24hour

25th /05/2017  

Time/date

HCT WBC PLT BP BT Color CRT Temp Pulsevolumn

Pulserate

intake symptom urine

7h00 110/70 36,5 pale 3s warm Strong 108 Dextran14drop/min

8h00 92/60 36,7 pale 3s warm Strong 112 Dextran14drop/min

restless

9h00 31,4 7,25 145 0 pale 3s cool Strong 0 dextran 10cc/kg

restless,coffeevomit, gum bleeding ,Blood sugar:59mg\dlIV: glucoseTest dengue

10h00 100/70 pale 2s warm Strong 120 Dextran7cc/kg

Sleep,Blood sugar: 118mg\dlDengue IgM : negativeIgG : positive

11h00 110/80 pale 2s cool Strong 110 Dextran 7cc/kg

Restless,CBCAdd : dopamine7dpm

Time/date

HCT WBC PLT BP BT Color CRT

Temp Pulse volumn

Pulserate

intake symptom urine

12h00 24,5 5,88 124 100/80 pale 3s cool 0 0 Dextran5cc/kg

restless,dyspnea ,melena,Lungs:crackles and decrease of breath sound both side. Discuss to family to find blood IVAdd: Lasix 20mg 1AAdd: bicarbonate

13hoo 100/80 37 pale 3s cool 0 0 Dextran5cc/kg

Drowsiness

14h00 113/80 37 cyanosis 4s cool 0 125 Dextran5cc/kg

drowsiness,tachypnea RR: 46

15h00 80/0 cyanosis 4s cool 0 120 Dextran5cc/kg

Gum bleeding ,petechiae and melena

16h00 80/60 cyanosis 4s cool 0 100 Dextran3cc/kg

restless

Time/date

HCT WBC PLT BP BT Color CRT

Temp Pulse volumn

Pulse rate

intake symptom urine

17h00 30,03 10,06 205 0 cyanosis 4s cool mail 100 Blood iv

18h00 0 cyanosis 4s cool 0 0 Blood iv Shallowbreath

19h00 0 cyanosis 4s cool 0 0 Blood iv Shallowbreath

20hoo 0 cyanosis 4s cool 0 0 Blood iv Shallowbreath. Time of death20h20, her family requested to take a child back to hometown. Total hospitalization time: 1 day and 12 hours

Final diagnosis� Severe dengue with hypotensive shock secondary to

severe bleeding� And possible fluid overload� Possible co-infection