Post on 16-Feb-2016
description
PICU AUDIT
Objectives
• To present a new approach of management of dengue fever
General Data
• LN• 2 year old• Female• 15.2 kg• February 27, 2012• Malaysian• Hindhu• Lives in Malaysia• Admitted last May 16, 2014
Chief Complaint
• Fever
History of Present Illness
11 days PTA
• Undocumented fever– Paracetamol – 1 day
• No other symptoms• No consult done
History of Present Illness
10 days PTA
• Fever resolved• Good appetite• Good activity
History of Present Illness
7 days PTA
• Fever Tmax 39• Consult in Malaysia– Serial CBCPC
LaboratoriesHg Hc WBC Neu Lym Mon
oEo Baso Plt
5/9 13.5 40 2.8 19 70 8 2 121 Atyp lym 1
5/10 12.9 39 2.1 28 58 10 3 1 137
5/11 10.9 35 2.7 18 68 10 3 1 106
5/12 13.2 41 3.6 14 70 11 4 1 139
Na K Cl Phos Ca Corrected Ca
5/9 134 4.2 99 1.69 2.23 2.27
LaboratoriesUrea Uric
acidGlucose
Crea
5/9 4.8 0.21 4.8 30 EGFR >90
TP A G A/G
5/9 65 38 27 1.41
Total bil
Total chol
ALP GGT AST ALT
5/9 2.8 3.9 181 16 47 33
DNS1 DB Mycoplasma Pneumonia antibody
5/9 Neg Neg 1:40 <1:40
History of Present Illness
4 days PTA
• Patient discharged• A> Viral Infection• Given Azithromycin
History of Present Illness
3 days PTA
• Afebrile• Playful• Active
History of Present Illness
Morningof admission
• Febrile– Paracetamol
• Poor oral intake• Decreased activity• Weak looking• Vomiting episodes• Consult TMC ER
ADMITTED
Past Medical History
• No asthma, allergies• No previous surgeries nor hospitalizations
Family History
• Hypertension• DM
Birth History
• Full term via NSD to a 42 year old G1P1 (1001)
Immunizations
• Complete for age• With booster doses
Feeding History
• Eats a regular diet• No food allergies
Review of Systems• General: No weight loss, poor appetite• Skin: Flushed, no rashes• Head: No migraines, dizziness and head injuries• Eyes: No blurring of vision• Ears: Good hearing, no tinnitus, earaches, infection, vertigo, no
discharges• Nose: No nasal stuffiness, discharge, and itching, nosebleeds,
and sinus trouble• Throat (Mouth/Pharynx): No sore tongue, dry mouth, sore
throat, hoarseness, and ache in the teeth and gums• Neck: No lumps, swollen glands, goiter, pain/stiffness of neck
Review of Systems• Cardiovascular: No palpitations, orthopnea, easy
fatigability• Respiratory: No cough, sputum, hemoptysis• Gastrointestinal: No diarrhea, constipation, nausea,
(+) vomiting, no abdominal pain• Genital: No genital infections, lesions.• Renal: No polyuria, dysuria, normal urine color• Neurologic: No fainting spells, seizures, paralysis,
numbness, and tremors• Psychiatric: No anxiety, tension, depression, and
memory change. He has never had suicidal attempts.
Physical Examination (ER)
• General Survey: Awake, ambulatory, not in cardiorespiratory distress
• Vital Signs: BP 90/60 HR 120 RR 25 T 38.6Height: 93 cm Weight: 15.2 kg
BMI 17.6 IBW 12 kg Pain scale 0/10
Physical Examination
• Skin: Flushed, good turgor
• HEENT: Normocephalic, pink palpebral conjunctiva, anicteric sclerae, nasal septum midline, hyperemic posterior pharyngeal wall
• Neck: Supple neck, Non palpable cervical lymph nodes, thyroid not enlarged
Physical Examination• Respiratory: Symmetrical chest expansion, no
retractions, clear breath sounds
• Cardiac: Adynamic precordium, normal rate, regular rhythm, no murmur
• Abdomen: Normoactive bowel sounds, Soft, non tender, no hepatomegaly
• Extremities: No cyanosis, swelling, full and equal pulses
Neurologic Examination
• Mental Status: GCS 15, conversant, active, irritable• Cranial Nerves: • Cranial nerves:
I – not assessedII – pupils 2-3mm ERTLIII, IV, VI – extraocular muscles intactV – intact corneal reflex V1, V2, V3 intactVII – no facial asymmetryVIII – intact gross hearingIX, X – good gag reflexXI – can shrug shouldersXII – tongue midline
Neurologic Examination
• Motor: 5/5• Cerebellar: No dysmmetria, dysdiadokinesia• Sensory: No sensory deficit• Reflex: +2 on all extremities• No babinski, meningeal signs
SYSTEMIC VIRAL ILLNESS
INITIAL IMPRESSION
Admitting Orders
Diagnostics• CBC• Urinalysis
Therapeutics• IVF: D5NM at Maintainance
+ 10 or 3.8 ml/kg• Paracetamol at 13 mkdose
q4 for T≥37.8
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
1st hospital stay
Day 2 of illness
No complaints
Poor oral intake
Urine output 1 ml/kg in 8 hours
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 126 RR 26 T 39.2-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
SVI r/o Dengue fever
Repeat CBCDengue Ns1Dengue blotDengue PCRBCS
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
Dengue Ns1: positiveDengue blot: negativeDengue PCR: Type 1
1st hospital stay
Day 1 of Illness
No complaints
Poor oral intake
Urine output 1.4ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 126 RR 26 T 38-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT>2sec
Dengue fever
IVF increased 3.8 ml/kgDaily cbc monitoring
2nd hospital stay
Day 2 of Illness
Loose stools + particles x 1
Urine output 2 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 112 RR 24 T 38.4-39.6FlushedPuffy eyelids, bilateralDry lipsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
Dengue fever
Decreased IVF to 3 ml/kgDaily cbc monitoring
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
3rd hospital stay
Day 3 of Illness
Loose stools x 2
Still with puffy eyes
Urine output 1.3 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 118 RR 26 T 38.1-40.2FlushedDecreased eye puffinessClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
Dengue fever
Decreased IVF to 2.7ml/kgProbioticsDaily cbc monitoring
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
4th hospital stay
Day 4 of IllnessOccasional
coughAbdominal
painNo recurrence
of loos stools
Urine ouput 1.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 110 RR 28 T 37.5-39.1FlushedMaculopapular rashes on faceOral soresClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses
Dengue fever
Fluid is maintainedDaily cbc monitoring
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
5th hospital stay
Day 5 of Illness
Persistence of abdominal pain
Urine ouput 2.9 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 110 RR 28 T 37.3-38.7FlushedMaculopapular rashes on facePuffy eyesOral soresClear breath soundsRegular rhythmAbdominal distentionFull pulsesNonpitting bipedal edema
Dengue fever with warning signs
Cardiac, liver enzymesKidney functionBleeding parametersElectrolytesAlbuminGastro referralCardiac referral
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
5/21 123 36 2.7 24 70 6 72 RL
Laboratories
CK total CK MB CKMM
5/21 662 84 578
Na K Ical
5/21 142 3.8 1.22
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
Gastro
• A> Dengue Hepatitis
5/21 Control Patient % Act INR
PT 12.4 11.4 1 0.95
PTT 29.6 48.7
Cardio
Cardio
• 2d echo– Small pericardial
effusion, pleural effusion, normal intracardiac structure
• A> Dengue Myocarditis
5th hospital stay (2 hrs prior to transfer)
DOB
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 120 RR 41 T 36
Decreased breath sounds on right base
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Transfer to PICUHGT 91Chest xray
AT PICU
Day 5 of IllnessNo abdominal
painNo recurrence
of loose stools
Urine output 2.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 105/52 HR 112 RR 69 T 36.9Flusheddecreased breath sounds right baseRegular rhythmSoft, nontender abdomen, no hepatomegalyFull pulses, CRT < 2 sec, warm extremities
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Serial cbc monitoring
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
5/21 123 36 2.7 24 70 6 72 RL
5/21 6pm
120 36 3.3 17 75 8 60 RL
5/21 11:30pm
106 31 3.8 24 69 7 52 RL
WBC vs Platelet
1 2 3 4 5 6 70
50
100
150
200
250
0
1
2
3
4
5
6
7
8
9
WBCPlatelet
Chest Xray
• Pleural effusion right
• Intercurrent Pneumonia not ruled out
AT PICU
No complaints
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
Albumin 2.0Hct 31 from 36 (14% decreased)
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
pRBC transfusion (5ml/kg)Albumin infusion (1g/kg)
1st PICU stay
Day 6 of IllnessGoing Day 1
afebrileMinimal
abdominal pain
Better well being
Urine output 2.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 118/70 HR 125 RR 34 T 37.3Flusheddecreased breath sounds right baseShallow subcostal retractionsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Serial cbc monitoring q6ElectrolytesAlbuminChest xrayFurosemide 0.4mg/kg/dose given 2 doses
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 6am
121 36 2.9 30 61 8 1 50
5/22 12pm
123 37 2.9 33 62 5 56 RL
5/22 6pm
117 35 3.2 30 63 6 1 56 RL
Laboratories
Na K Ical
5/21 142 3.8 1.22
5/22 140 3.8 1.13
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
Chest Xray
• Regressing pleural effusion right
• Intercurrent Pneumonia cannot be totally ruled out
2nd PICU stay
• Day 7 of Illness
• Going Day 2 afebrile
• No complaints
• Better well being
• Urine output 2 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 107/60 HR 88 RR 24 T afebrileFlushedHarsh breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
Serial cbc monitoring q12ElectrolytesAlbuminCardiac enzymesPTCreatinine
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 121 36 2.9 30 61 8 1 50
5/22 123 37 2.9 33 62 5 56 RL
5/22 117 35 3.2 30 63 6 1 56 RL
5/236am
118 35 3.3 28 67 2 3 88
5/23 6pm
112 33 3.3 18 72 7 3 116 RL
LaboratoriesNa K Ical
5/21 142 3.8 1.22
5/22 140 3.8 1.13
5/23 138 4.1 1.1
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
5/23 3.4 0.42
CK total CK MB CKMM
5/21 662 84 578
5/23 268 76 192
3rd PICU stay
Day 8 of illnessGoing Day 3
afebrileBetter well
beingImproving
appetiteUrine output
1.3 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/70 HR 88 RR 22 T 36.7PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
Transfer to regular room
8th hospital stay
Day 8 of illness
Going Day 3 afebrile
Noisy breathing
DysuriaUrine output
1 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/70 HR 88 RR 22 T 36.7PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
UrinalysisSalinase
5/25Color Dark yellow RBC 2
Transpency Slightly cloudy WBC 7
pH 7.0 Epithelial cells 15
Specific gravity 1.010 Casts 0
Blood + Bacteria 24
Protein +
Glucose -
Leucocytes +
Ketones +
Urobilinogen +
Bilirubin +
Nitrites -
Laboratories
9th hospital stay
Day 9 of illness
Going Day 4 afebrile
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 90 RR 24 T 36.9PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue MyocarditisUTI
May go home
LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 121 36 2.9 30 61 8 1 50
5/22 123 37 2.9 33 62 5 56 RL
5/22 117 35 3.2 30 63 6 1 56 RL
5/23 118 35 3.3 28 67 2 3 88
5/23 112 33 3.3 18 72 7 3 116 RL
5/26 136 41 5.8 24 66 8 2 164 RL
Laboratories
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
5/23 3.4 0.42
5/26 91
Discharge
• Discharged on the 8th Hospital stay• Home medications– Cefuroxime (dose) for UTI
• Follow up prior to going back to Malaysia
DENGUE HEMORRHAGIC FEVERDENGUE HEPATITISDENGUE MYOCARDITIS
Final Diagnosis