Friday, January 09, 2015

Long Case with Dr. Che Rosle

My 22-year-old sister just came back from her university for holiday. She saw me sitting at my table in my room, reading CPG on my laptop, and asked, 'Kak Ain, do you have exam?' Then I said 'No. Why?' 

She replied, 'Then why are you studying?' 


Is it really obvious that I only study if I have exam? Hahahaha.

Your sister here is trying to be a liiiiiitle bit hardworking, silence please :P

Okay people. 

So this morning, we had discussed on dengue fever and acute exacerbation of bronchial asthma.

Patient 1 
24-year-old female presented with one week history of intermittent fever with chills and rigor associated with frontal headache, retroorbital pain, arthralgia, myalgia and lethargy. No history of neighbourhood dengue, recent travelling or swimming.

Examination was done on Day 10 of admission. No significant findings except for epigastric tenderness.

Let's do a pop quiz.

1. Incubation period of dengue infection?

4 to 7 days (range 3 -14)

2. Clinical courses of dengue infection?

Febrile, Critical and Recovery phase

3. Seven clinical warning signs of severe dengue or high possibility of rapid progression to shock?

  • Restlessness
  • Mucosal bleed
  • Altered level of consciousness
  • Abdominal pain
  • Persistent vomiting
  • Tender hepatomegaly > 2cm
  • Lab investigations (high haematocrit, low platelet)
  • Clinical fluid accumulation (pleural effusion, ascites)

4. Manifestation of generalised vasoconstriction in various systems?
  • Skin - coolness, pallor and delayed capillary refill time
  • CNS - lethargy, restlessness, apprehension, reduced level of consciousness
  • CVS - raised diastolic blood pressure and a narrowing of pulse pressure
  • Respiratory - tachypnoea (respiratory rate > 20/min) 
  • GIT - vomiting and abdominal pain
  • Renal - reducing urine output

5. Common late complications of prolonged shock?

Massive bleeding, DIC and multi-organ failure

6. Clinical findings in compensated and decompensated shock?

7. Why secondary infection with a heterotypic dengue virus is associated with increased risk of developing DHF?

Due to antibody-dependent enhancement phenomenon. 

The sub-neutralising concentration of the cross-reacting antibody from the previous infection may opsonise the virus and enhance its uptake and replication in the macrophage or mononuclear cells. The level of T-cell activation is also enhanced. 

Profound T-cell activation with cell death during acute dengue infection may suppress or delay viral elimination, leading to the higher viral loads and increased immunopathology found in patients with DHF.

8. How to perform Tourniquet Test?

Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressures for 5 minutes. A positive test is when 20 or more petechiae per 2.5 cm (1 inch) square are observed.

9. WHO case definition of DF, DHF and DSS?

Dengue fever

Dengue Haemorrhagic Fever

Dengue Shock Syndrome

10. Classification based on severity?

11. Differential diagnoses?

12. Diagnostic Tests?
  • Dengue Serology Test - Haemagglutination Inhibition Test, IgM capture ELISA Test, Indirect IgG ELISA Test, Rapid Dengue Test
  • Virus isolation
  • PCR
  • Non-structural Protein-1 Antigen Test

13. Management of dengue with warning signs?

Patient 2
45-year-old lady with underlying bronchial asthma diagnosed 9 years ago, presented with two weeks history of worsening shortness of breath associated with noisy breathing, chest tightness, mild intermittent fever and productive cough. 

For the past one month, she had more than twice day time and night time symptoms. The symptoms were precipitated by cold weather. Her activities were limited when symptoms occurred. There was need for reliever. On the day of admission, her symptoms could not be relieved by MDI Salbutamol and Budesonide, or nebuliser. 

She had asthma attack once every 2 years. Her last attack was in July 2014. There was no history of intubation or ICU admission. She claimed to be compliant to medications.

She is an active smoker, since 28 years ago, 1 cigarette per day.

Examination was done on Day 1 of admission. Patient was mildly obese, on nasal prong 3L/min. Throat mildly injected. Respiratory Rate 23 breaths per minute. On respiratory examination, generalised rhonchi was heard bilaterally with prolonged expiratory phase. Fine crepitations heard at right lower zone of right lung.

1. Differential diagnoses?
  • Acute Exacerbation of Bronchial Asthma (AEBA)
  • Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

2. How do you diagnose asthma?

3. How to assess level of asthma control? 

4. What are the four components of asthma care?
  • Develop patient/doctor partnership
  • Identify and reduce exposure to risk factors
  • Assess, treat and monitor asthma
  • Manage asthma exacerbations

5. Management approach?

6. How to assess severity of asthma exacerbations?

7. Asthma medications?

  • Glucocorticosteroids - Inhaled (Budesonide, Beclomethasone, Fluticasone, Mometasone, Triamcinolone) or Tablets/Syrups (Hydrocortisone, Methylprednisolone, Prednisolone)
  • Long-acting beta agonists - Inhaled (Formoterol, Salmeterol) or Sustained-release tablets (Salbutamol, Terbutaline, Aminophylline)
  • Antileukotrienes - Montelukast, Zafirlukast
  • Sodium cromoglycate - Cromolyn
  • Nedocromil - Cromones
  • Immunomodulators - Omolizumab, Anti-IgE

  • Short-acting beta agonists - Albuterol/Salbutamol, Fenoterol, Terbutaline
  • Anticholinergics - Ipratropium bromide
  • Short-acting theophylline - Aminophylline
  • Epinephrine/adrenaline injection

  • CPG Management of Dengue Infection in Adults, Revised 2nd Edition 2010, by MOH Malaysia, can be downloaded here
  • Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years) GINA Guideline, Updated 2012 can be downloaded here

Have a good nightt! :)

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