CASE PRESENTATION : - PowerPoint PPT Presentation

CASE PRESENTATION ສະເໜີໂຈງ : ອສ ຈຣ ວາລີ ແກ້ວຫຼວຄໂ຃ຈ ( ຃ະນະສາງພາງໃນ , ຫົວໜ້າພະແນກ ຆຶມເຆື້ຬ - ເຂຈອ້ຬນ ໂອຄໝ ໍ ມະໂຫສົຈ ) ພ້ຬມທີມຄານ : ຈຣ ກໍ ຅ ັ້ ຄ ຈຣ ສົມຬາພຬນ ຅ ັ ນກຬຄສິນ 1

CASE 1 2

General information • A female, 29 years old • Occupation: housewife • Address: Naxu village Vangvieng district Vientiane province 3

CC: fever PHI: - Patient has had fever for 10 days, high grade fever with chill associated with strong headache, myalgia. - Patient had urine burning and painful 3 days before admitted, but no low back pain, no dark urine, no diarrhea, no cough, no nausea and vomiting 4

PMH: • No DM/HTN/ TB. No history of surgery • No history of allergy, No smoke/drink • FML: healthy, no TB, no Cancer. PE: Good consciousness ▪ Vital sign: BP: 90/50 mmHg, PR: 100 bpm, RR :22bpm, T:39  c Sao2: 97%(room air), BW: 45 Kg. ▪ HEENT: Head : no head trauma, no alopecia Ears : no deafness, no tinnitus Eyes : pale conjunctiva, no ictero-sclera 5

PE (con’t) Nose : no running nose Neck : no lymph node , no JVD Throat : no red pharynx, no tonsillitis  Heart : JVD, regular rhythm, no murmur. ▪ Abdomen : soft, no Ascites, no mass, Murphy, no hepato-splenomegaly  CVAT: positive at left side ▪ Joints : no deformity ▪ Neuro : CN 12: normal, power +5 all, reflex : normal, sensory: normal. ▪ Skins: no pallor, no rash, no jaundice ▪ Extremities: No pitting edema 6

Problem lists  Fever  Headache  Myalgia.  Low back pain  Urine burning and painful  Costo vertebral angle tenderness positive 7

Differential diagnosis 1. Acute pyelonephritis 2. Rickettsial disease 8

Labs results 16/12/16 20/12/16 9

Result Lab • Serology rickettsial negative • U/S : normal 10

Empirics treatment 1. Ceftriaxone 2g/days 2. IV fluid 3. Paracetamol three days after on the antibiotic Patient still has fever + low back pain Result from Microbiology Lab found 11

26/12/16 12

Final diagnosis • Septicemia due to E.Coli ESBL* *Extended Spectrum Beta-Lactamases 13

Treatment (con’t ) off ceftriaxone and switch to • Amikacin 250mg 1flx2/days For 7days switch to oral medicine • Nitrofurantoin 1tablet 4time /days for 7days 14

CASE 2 15

General information • A male, 20 years old • Occupation: worker • Address: Napho village Hinphun district khammoun province 16

CC: chronic fever PHI: • Patient has had Fever for 5 days high grade fever, myalgia, strong headache, associated with nausea and vomiting • 5 days admitted at Thakhek hospital, unknown treatment • Then,5 days admitted at Nakhounpanum hospital, not improved • After that, went to Menumkhong Hospital for 5 days But the patient worst so they are refer patient to Mahosot hospital 17

At Mahosot hospital • Patient has had low grade fever  Headache  Nausea and Vomiting PMH: • No history of allergy. No smoke/drink • No amphetamine use • FML: his grandfather death with PTB 18

Physical examination ▪ General status: unconsciousness (GCS: 11) ▪ Vital sign: BP: 90/50 mmHg, PR: 110 bpm, RR :22bpm, T:38 Sao2: 94%(room air), BW: 53 Kg. ▪ HEENT: Head : no head trauma, no alopecia Ears : no deafness, no tinnitus Eyes : pink conjunctiva, no ictero sclera Nose : no running nose Neck : no lymph node , no JVD Throat: no tonsillitis, no oral thrust 19

Physical examination ▪ Heart : JVD -, regular rhythm, no murmur. ▪ Abdomen : soft, No Ascites, No mass, No hepato- splenomegaly ▪ lung: clear no crepitation ▪ Neuro : power 4/5 4/5 hyper reflex both leg 3/5 4/5 Neck stiffness : Positive Kernig sign positive Brudzinski’s positive ▪ Skins: no PPE, no pale, no rash, No pitting edema 20

Problem lists • Chronic fever • Headache • Nausea and vomiting • Neck stiffness positive • Kernig sign positive • Brudzinski’s sign positive • Lose power for both leg and arm • GCS: 11 21

Differential diagnosis 1. Meningitis 2. Brain abscess 3. Encephalitis 22

Labs results 23

CSF result Albumins 32 Glucose 29 HIV TEST: negative 24

CXR 25

CT scan Brain 26

Treatment At ICU: • Ceftriaxone 2g every 12h • Dexamethazone 8mg every 6h • Omepalzole • Perfalgan Treat for 4days the patient get better so refer to IDA 27

Treatment at IDA ward • Patient had Good conscious, GCS: 15 • Still headache • Low grade fever • Neck stiffness negative • Lost power grade 4 for both arm, right leg grade 3 and left leg grade 4 • PT slow communication 28

Final diagnosis • Patient still have fever • CSF result : High Lymphocyte count Low Glucose Tuberculosis Meningitis 29

Treatment (con’t) • Ceftriaxone 2g every 8 h • Dexamethazone 8mg every 6 h • Rehabilitations For 2 days treatment at IDA and after that add Anti TB with 4 FDC: 4 tablet/days until 21 days off treatment Discharge 30

CASE 3 31

General information • A male, 64 years old • Occupation: retired • Address: Nakhunnoi village Nasaythong district Vientiane Capital 32

CC: chronic fever PHI: • Patient has had pain at col femoral area after he was full down at his house and admitted at Mittaphab hospital for 2weeks • When admitted at Mittaphab Hospital the patient has had fever, high grade fever, associated with melena. • So they refer the patient to Mahosot Hospital and admitted at ICUA ward 33

At Mahosot hospital Patient has had high grade fever  Dry cough  Right leg pain ( can’t move) PMH: • No history of allergy. No smoke/drink • DM for 2 years poor control • FML: healthy 34

Physical examination ▪ General status: consciousness ▪ Vital sign: BP: 80/50 mmHg, PR: 120 bpm, RR :22bpm, T:39 Sao2: 90%(room air), BW: 65 Kg. ▪ HEENT: Head : no head trauma, no alopecia Ears : no deafness, no tinnitus Eyes : pale conjunctiva, no ictero sclera Nose : no running nose Neck : no lymph node , no JVD Throat: no tonsillitis, no oral thrust 35

Physical examination ▪ Heart : JVD -, regular rhythm, no murmur. ▪ Abdomen : soft, No Ascites, No mass, No hepato-splenomegaly ▪ lung: crepitation (right side) 5/5 5/5 ▪ Neuro : power 5/5 5/5 reflex both leg normal sensory normal ▪ extremity : pitting edema both leg, right leg pain hot red difficult to move, no PPE, no rash, 36

Problem lists • Chronic fever • right leg pain (swelling, hot, red) • dry cough • crepitation (right side) • DM poor control 37

Differential diagnosis 1. Disseminated Melioidosis 2. Septic artritis 3. Pneumonia 38

Labs results 39

Labs results 40

CXR 41

U/S 42

X-ray col felmural 43

Hemoculture 44

Uro culture 45

Pus culture 46

Final Diagnosis • Disseminated Melioidosis • DM type II 47

Treatment  At ICU: • Ceftazidime 2g every 8h • Blood transfusion • Omeprazole • Insulin R  Treat at ICUA 19 th days after that refer patient to IDA continuous treat 48

Thanks for your attention 49