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Location :
C/O:
Referred from KK Ulu Tiram TRO Leptospirosis
HOPI:
Patient was apparently well claim started until last friday
Lethargy
-claim was been feeling more tired and weak since Friday
-+myalgia and arthalgia
On further history noted patient has been feeling unwell and lethargy for the
past one week.However fever only started 3days ago.Patient claim went to Dentist one week
ago,informed
BP low,advice to go hospital,however patient did not seek medical attention.
Otherwise
no rashes,no retroorbital pain
no gum bleeding,no mucosal bleeding
no abdominal pain,no vomitting,no diarrhea,no abdominal distension
no chest pain,no sob
no headache,no dizziness
no fainting episodes
no UTI ssx
no cough/URTI ssx
Patient went to KK Ulu Tiram today noted BP 56/26,after repeated BP 67/28>>run fast one
pint NS>>BP 86/49,PR 50,T 37.8,SPO2 99% under RA.Otherwise lung clear,cvs drnm,pa
snt.Patient referred to EDHSI for further management
In EDRZ noted BP 90/53 PR 70 ,T 38.3,started IV Gela Bolus
5cc/kg/hr(250cc/hr)@1300H,IV Noradrenaline running at 0.05mcg/kg/min.
Family and Social history:
Patient married,blessed with 3children.Currently staying with wife and childrens in Ulu
Tiram.Working as a technician in Desa Cemerlang.Active smoker for the past 15
years,around 15sticks per day.Denies alcohol intake,IVDU and high risk behaviour.No
family history of DM,HTN and malignancy.No history of dengue in family and
neighbours.Denies any recent fogging and dengue incident in housing area and working
place.No history of recent travelling
O/E
Alert
Conscious
Lethargy+
Clinically pink
Hydration fair
CRT<2sec
On going IVD 3cc bolus@14.30H
VS
BP 104/59 on ivi noradrenaline 0.05mcg/kg/min
PR 69bpm
SPO2 98% under RA
T 38.3'C
GM 6.9
Ix
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin
Wbc 9.17 7.8 6.6
Hb 14.7 12.1 12.7
Plt 117 75 106
Hct 41.4 34.4
UFEME
Leu -ve
Nit -ve
RBC 1+
Ketone 1+
RP
Na 136
K 3.9
Ur 6.8
Cr 90
Dengue serology 15/7
IgM -ve
IgG -ve
NS1 antigen -ve
CXR Clear
Impression:
Septic shock 2' TRO Leptospirosis
Plan
Admit ward 7A(acute cubicle)
VS monitoring
Strict I/O Charting
Titre IVI Norad accordingly
-Keep MAP > 65
* Final Report *
Document Contains Addenda
Patient Progress Note (Doctor)
Location :7A
Impression:
Septic shock TRO Leptospirosis
C/O:
Referred from KK Ulu Tiram TRO Leptospirosis
HOPI:
Patient was apparently well claim started until last friday
Fever
-started 3days ago
-on Friday (13/7) at around 11pm
-claim sudden onset,on and off
-a/w chills and rigor,resolved with PCM,claim took 2pils,last taken at 6.30am
today
-claim took temperature yesterday night,40.5'c
Lethargy
-claim was been feeling more tired and weak since fri
-+myalgia and arthalgia
Claim feeling nauseated since today morning
Otherwise
no rashes,no retroorbital pain
no gum bleeding,no mucosal bleeding
no abdominal pain,no vomitting,no diarrhea,no abdominal distension
no chest pain,no sob
no headache,no dizziness
no fainting episodes
no UTI ssx
no cough/URTI ssx
On further history noted patient has been feeling unwell and lethargy for the
past one week.However fever only started 3days ago.Patient claim went to Dentist
one week ago,informed
BP low,advice to go hospital,however patient did not seek medical attention.
Afebrile
on IV Ceftriaxone 2g OD -D4
O/E
Alert, conscious
Clinically pink
Hydration good
Good pulse volume
CRT<2sec
VS
BP 104/62mmHg, unsupported
PR 70bpm
T 37.0'C
SpO2 97% under RA
Lungsclear
CVS DRNM
PA liver palpable 2FB
Investigation:
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin 16/7 17/7
Wbc 9.17 7.8 6.6 10.7 8.0
Hb 14.7 12.1 12.7 13.9 12.3
Plt 117 75 106 137 106
Hct 41.4 34.4 40.2 34.5
UFEME 15/7
Leu -ve
Nit -ve
RBC 1+
Ketone 1+
RP 15/7 16/7
Na 136 137
K 3.9 3.3
Ur 6.8 5.3
Cr 90 77
Viral screening : NR
CXR Clear
Plan
VS monitoring hourly
Keep MAP>65
Keep SpO2>95%
Strict I/O Charting
Off CBD -patient requested. For patient self-charting IO
Off IVD
Off IV Ceftriaxone 2g OD
Start IV Cloxacillin 500mg Q4H
Plan:
allow AOR discharge
TCA IMC 2 weeks
Discharge with:
T Cloxacillin 500mg QID x 1 week
* Preliminary Report *
Discharge Summary
DOA: 15-July-2018
DOD: 18-July-2018
ICD-10: R65.21
Final Diagnosis:
Septic shock TRO Leptospirosis
Case summary:
This 32 years old gentleman, presented with history of fever for 3days, associated
with lethargy, myalgia, arthralgia and nausea. Intially went to KK Ulu Tiram,
patinet noted to be hypotensive. Thus, referred to HSI for further management. In
ED, noted persistantly hypotensive despite fluid resuscitation, hence started on
inotropic support, with maximum requirement 0.3mcg/kg/hour. Able to weaned off
IVi Noradrenaline this morning, ranging BP 95-110/57-68mmHg with MAP >65.
Otherwise, patient well, tolerating orally, no other active issue. However, patient
keen for AOR discharge today.
VS
BP 99/57mmHg, unsupported
PR 72bpm
T 36.8'C
SpO2 96% under RA
Lungsclear
CVS DRNM
PA liver palpable 2FB
Investigations:
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin 16/7 17/7
Wbc 9.17 7.8 6.6 10.7 8.0
Hb 14.7 12.1 12.7 13.9 12.3
Plt 117 75 106 137 106
Hct 41.4 34.4 40.2 34.5
UFEME 15/7
Leu -ve
Nit -ve
RBC 1+
Ketone 1+
RP 15/7 16/7
Na 136 137
K 3.9 3.3
Ur 6.8 5.3
Cr 90 77
Viral screening : NR
CXR Clear
Discharge plan:
Allow AOR discharge
TCA IMC 1 month with ECHO and to review TFT result
Discharge with:
T Cloxacillin 500mg QID x 1 week