1 ED CLERKING 27 / M / , NKMI, Chronic smoker C/o: - abdominal pain X1/7 - mainly @ epigastric region - started suddenly @ 3pm today - pricking in nature , persistent - 0 radiation - not relieved by PCM taken @ 1.30pm today A/w:+ diarrhea X1/7 - 3 times since today morning - loose stool , unsure color & whether has blood in feces + lethargy - on MC X3/7 due tofever + URTI : Rx as bacterial URTI by GP, completed Abx X3/7 + h/o fever X3/7 started on Thursday (1/5/2023) @ 9am - fever resolved since today noon @ ~12noon + u/o: last voiding @ 6am today oral intake; taken only ~ 250cc plain water since morning, poor appetite Otherwise , no nausea / vomiting no spontaneous mucosal bleeding / rashes no SOB / chest pain / cough no recent travelling / jungle trekking + stay in dengue prone area - h/o fogging last week Allergy hx; NKDA / no h/o food allergy PMHx; Nil PSHx; Nil O/e: alert, GCS 15/15, dehydrated CVS : DRNM, 0 muffled heart sound Lungs BP: 129/76 PR : 102 bpm T0 : 37o C SPO2: 97% RA cracked lips dry, coated tongue Clear A/e good & equal 0 creps / rhonchi 4/5/23 1500h
2 PA : Plan: Liver not palpable Tender @ epigastric 0 guarding Ix: FBC - HCT: 45 - Hb: 12.3 - Plt: 140 - TWC: 3.5 Rapid combo test: Not available DF Day 4 of illness (PT; 1/5/23 @ 9am) in critical phase 5 hours (since 12 noon today) with warning signs; lethargy, abdominal pain , multiple diarrhea Dr. Muhammad Bin Abdul Rahim Pegawai Perubatan Siswazah UD41 Pusat Perubatan Medicorp MMC No: 54321
3 Admission review 27 / M / , NKMI, Chronic smoker BMI 21, BW; 60kg DF Day 4 of illness (PT; 1/5/23 @ 9am) in critical phase 12 hours with ; - resolved compensated dengue shock - given graded bolus @ED - resolved warning sign; lethargy, abd pain , diarrhea - NSI +ve @ ED, dengue serology sent - notification & dengue registration sent Plan (S/B Specialist) 1) Encourage orally as tolerated 2) Continue IVD 1.5cc/kg/h 3) For TDS r/v by MO 4) Strict I/O chart, aim u/o > 0.5cc/kg/h 5) FBC TDS, daily BUSE 6) Trace dengue serology 7) KIV refer surgical if abd pain recurs 5/5/23 0010h Ix FBC tds BUSE OD Dr. Muhammad Bin Abdul Rahim Pegawai Perubatan Siswazah UD41 Pusat Perubatan Medicorp MMC No: 54321
4 AM review 27 / M / , NKMI, Chronic smoker BMI 21, BW; 60kg DF Day 4 of illness (PT; 1/5/23 @ 9am) in critical phase 19 hours with ; - resolved compensated dengue shock - given graded bolus @ED - resolved warning sign; lethargy, abd pain , diarrhea - NSI +ve @ ED, dengue notification sent - on IVD 1.5cc/kg/h Currently, abd pain resolved , current pain score 0 oral intake much improved; - taken 500cc since admission last midnight last PU 5am - 500cc Clear urine Otherwise , no vomiting / diarrhea , denies lethargy / dizziness, no spontaneous mucosal bleeding, no SOB / chest pain O/e: alert, GCS 15/15, pink , comfortable hydration fair; moist tongue CVS : DRNM, 0 muffled heart sound Lungs PA: Soft, not tender V/S stable since admission BP: normal range , no narrowing pulse pressure PR : normal range , no episodes of tachycardia T0 : afebrile since admission SPO2: 98% RA I/O = +630cc U/O: 500c/60kg/7h = 1.2cc/kg/h Clear equal a/e FBC - HCT: ___ - Hb: ____ - Plt: ____ - TWC: ____ IgM; -ve IgG; +ve LFT - N RP - N 5/5/23 0700h
5 Revised ; Secondary DF, Day 4 of illness in critical phase 19 hours with resolved compensated shock & warning signs Plan 1) Reduce IVD to 1.2cc/kg/hour 2) Encourage orally 3) W/out warning signs (recurrent abd pain , evidence of leaking, mucosal bleeding) 4) Inform if BP < 100/70, narrowing pulse pressure 5) Continue FBC TDS Ix FBC tds Dr. Muhammad Bin Abdul Rahim Pegawai Perubatan Siswazah UD41 Pusat Perubatan Medicorp MMC No: 54321