Multisystem Processes & Disorders

Frame 1

"Please fill out this prescription - and make sure you complete the course of the medication" you say with a smile to the pleasant older gentleman whom you've just diagnosed with low-grade, community acquired pneumonia.

He's the third patient with pneumonia to visit your clinic this morning, and it's only 11.30 a.m.

"I guess it's that season again", you mutter under your breath.

You're sorting through some clinical dictations and case notes when the nurse calls the next patient in. You start reading through her case file.

Frame 2

Tamaya is a 23-year-old university student who complains of fever for the last two days.

You introduce yourself and ask how you can help her today.

"Doctor, I've been having a fever and shivering for the last two days. It started suddenly, out of nowhere! I haven't been able to eat or drink much since," she says, looking fatigued.

Frame 3

On further probing you learn that Tamaya's fever is cyclical and associated with chills, rigors and malaise.

She also complains of generalized muscle and joint pain, especially in her knees and shoulders.

This morning, she woke up with a headache, mainly affecting her forehead and around her eyes. She describes it as a sensation of 'pressure' and 'stuffiness'.

She also says that her skin seems flushed after each episode of fever. She denies vomiting, neck stiffness or sensitivity to light.

You further discover that she recently returned from a two month trip to Southeast Asia. She was healthy throughout her holiday, except for some insect bites.

Frame 4

On inspection, she seems quite fatigued. You notice flushing over her cheeks and forehead

Her vitals are as follows: BP 127/92 mmHg, pulse 102 bpm, O2 saturation 98% on room air, and a respiratory rate of 22 cycles/min.

She is febrile, with a temperature of 101 ˚F (38.3 ˚C). There is lymphadenopathy of the submandibular and axillary nodes.

Her heart sounds are normal, although she is slightly tachycardic, with clear lung fields. She has generalized abdominal tenderness but no swelling, rebound tenderness or guarding. No abdominal organs are palpable.

Frame 5

Her blood panel, and renal and liver function tests read as follows:

Hb: 13.2 g/dL (12 - 15.5)

PCV: 0.45 (0.35 - 0.45)

White cell count: 2,000/mm3 (3,500 - 10,500)

Platelet count: 101,000/mm3 (150,000 - 450,000)

BUN: 21 mg/dL (7 - 20)

Serum creatinine: 1.14 mg/dL (0.6 - 1.1)

AST: 64 IU/L (9 - 48)

ALT: 55 IU/L (7 - 55)

Frame 6

What do you do now?

Choice Outcome Score Continues
Admit Tamaya, start supportive therapy, and order tests for the dengue virus Correct 1 → Frame 7
Order tests for the dengue virus, prescribe antipyretics, and ask her to return in 2 days Incorrect 0 → Frame 9
Prescribe co-amoxiclav, and send her home for follow up in two weeks Incorrect 0 → Frame 8

Frame 7

You suspect dengue fever based on her signs and symptoms, laboratory findings, and most importantly, her recent history of travel to a region known to be endemic for this disease.

You discuss the likely diagnosis, and say that as she has several warning signs, you'd like to admit her for monitoring and rehydration, to which she agrees.

You proceed to order the relevant lab tests for dengue, including ELISA for dengue-specific IgM and a septic screen, and inform the admissions office and nursing staff of your decisions.

Frame 8

You're surprised to see Tamaya in the emergency department the next day. She is in the process of being admitted by the medical team.

A quick chat with one of your colleagues reveals a likely diagnosis of dengue fever. The relevant blood panels have been sent to confirm this.

Meanwhile, you inform him of her consultation yesterday, and request a transfer-of-care to your team.

Frame 9

You tell Tamaya that she most likely has dengue fever, and arrange for the relevant diagnostic studies.

You also inform her that as her symptoms are relatively mild, she can go home for now, but should immediately return to hospital if she worsens. You ask her to take acetaminophen for the fever.

That very evening, you recieve an angry phone call from Tamaya's mother.

She had collapsed while at a lecture, and has been taken to a different hospital, where she has been diagnosed with dengue shock syndrome.

She wants to know why her daughter was not admitted if you suspected dengue, and keeps calling your actions medical negligence.

Promising a lawsuit as soon as her daughter gets better, she slams the phone down ....

The end

Frame 10

Tamaya is admitted to your ward. You request twice-daily blood draws and the recording of a fluid input/output chart to monitor her renal function and hydration.

You also order that intravenous normal saline be administered over four-to-six hours initially and later adjusted as per her volume status, for maintenance.

Frame 11

Two days later, your pager beeps. It's the nurse, informing you that Tamaya's clinical condition has deteriorated.

She seemed to be improving as yesterday, but a short while earlier, her blood pressure dropped to 98/78 mmHg with pulse of 122 bpm.

Frame 12

You proceed to Tamaya's room rapidly and take a look at her.

Tamaya's peripheries are cold to the touch, with a capillary refill time of 4 seconds. You find a discreet, widespread petechial rash over her trunk and lower limbs.

She is tachypneic at 34 breaths/min, with a BP of 103/89 mmHg and pulse of 125 beats/min. You note a slightly enlarged liver, around 3cm below the right costal margin.

Auscultation of her chest reveals bilateral wheezing, and coarse crepitations up to the mid-zone. A portable chest X-Ray shows bilateral pleural effusions.

Frame 13

You very rapidly go over her blood work; the serology has confirmed dengue fever.

Her most recent lab results (which were obtained within the last hour) are as follows:

Hb: 12.5 g/dL (12 - 15.5)

PCV: 0.65 (0.35 - 0.45)

White cell count: 2,200/mm3 (3,500 - 10,500)

Platelet count: 64,000/mm3 (150,000 - 450,000)

Urea: 31.6 mg/dL (7 - 20)

Creatinine: 1.69 mg/dL (0.6 - 1.1)

AST: 210 IU/L (9 - 48)

ALT: 185 IU/L (7 - 55)

Bilirubin and alkaline phosphatase: Within normal parameters

lNR: 1.4

You run through the next steps of action in your head while preparing to send for blood gases.

Frame 14

What will you do now?

Choice Outcome Score Continues
Maintain the current fluid rate, order an ultrasound-guided pleural tap and chest drain placement, and consider transferring her to the high dependency unit (HDU) Incorrect 0 → Frame 15
Fluid resuscitation with isotonic crystalloids, and consider transferring her to the HDU Correct 1 → Frame 16
Maintain her on the current fluid rate, start piperacillin-tazobactam, and consider transferring her to the HDU Incorrect 0 → Frame 15

Frame 15

You are in your office filling out the relevant paperwork, when you hear a commotion in Tamaya's room.

Running over, you discover that she suddenly became unresponsive just moments ago. The nurses say that she was restless and confused for several minutes beforehand.

You conduct a quick survey and ask for chest leads to be put in place. While doing so, it dawns on you that your original plan was incorrect, as this is most likely dengue shock syndrome.

Frame 16

You realize that Tamaya is developing dengue shock syndrome and is intravascularly depleted due to the increased vascular permeability and plasma leakage that are characteristic of the condition.

She is already in compensated shock, and is showing features suggestive of progression into hypotensive shock.

You put in an emergency order for a fluid bolus with isotonic crystalloids and order arterial blood gases, then pick up the phone to request a transfer to the HDU.

Frame 17

Tamaya is in the supine position, with a nurse at the head of the bed administering oxygen and protecting her airway.

Defibrillator pads have been securely attached and the ECG shows a narrow-complex tachycardia of 170 bpm. Both peripheral and central pulses are absent.

Frame 18

What do you do now?

Choice Outcome Score Continues
Commence CPR, intubate and ventillate her, and administer a fluid bolus Correct 1 → Frame 20
Administer epinephrine 1mg, and consider amiodarone 300mg followed by CPR Incorrect 0 → Frame 19
Defibrillate her at 120-200J (biphasic), followed by CPR Incorrect 0 → Frame 33

Frame 19

Time seems to slow down as you work towards resuscitating your patient. However, despite your best efforts, you fail to obtain return of spontaneous circulation (ROSC).

You work tirelessly to no avail for 45 minutes before realizing that further effort is futile.

Your colleague gestures towards the clock; you need to note the time of death.

The end

Frame 20

You quickly and accurately assess Tamaya's condition as pulseless electrical activity (PEA), most likely due to decompensated hypovolemic shock.

Thus, you immediately commence CPR, and intubate and ventillate her with 100% oxygen. Thanking your lucky stars for the already established venous access, you also administer a fluid bolus.

You assess Tamaya's ECG from the continuous monitor, while CPR continues. Following aggressive fluid resuscitation, she returns to sinus rhythm with a detectable pulse.

You instruct the team to proceed with the post-arrest cardiac care protocol, including ordering a complete blood count, coagulation profile, serum electrolytes, and blood gases.

Subsequently, portable echocardiography reveals no evidence of myocardial dysfunction.

Frame 21

Tamaya is transferred to the high dependency unit (HDU) for intensive monitoring and observation. She is currently stable and maintaining her own airway.

You commenced a 10mL/kg bolus of normal saline over an hour with continuous monitoring of fluid output, and leave instructions to repeat the complete blood count at the end of the hour.

Frame 22

An hour later, Tamara's condition hasn't changed much. She has also not been passing adequate urine (less than 0.5/kg/hour).

Her blood work shows that her PCV has increased from 0.65 to 0.75, with a hemoglobin of 12.2 g/dL.

Frame 23

What do you do now?

Choice Outcome Score Continues
Initiate a blood transfusion Incorrect 0 → Frame 24
Repeat a second bolus of fluids at a rate of 20 mL/kg/hour Correct 1 → Frame 25

Frame 24

You are about to phone the blood bank to order two units of blood when the intensivist intervenes.

"I'm a little confused as to why you're ordering blood for this patient. Is there any evidence of bleeding?"

"Maybe we should try administering another fluid bolus, at a faster rate this time," she continues. Somewhat embarassed, you agree.

Frame 25

Tamaya's vitals improve after administering the second bolus and you notice an adequate amount of urine in the collection bag.

You perform a quick review of the systems to find a moderate improvement in her breath sounds; her heart rhythm remains stabilized.

You adjust the rate of the fluids to 10 mL/kg/hour for the next two hours and prescribe a gradual reduction of fluids for the night.

You then make your way to the on-call room, ready for some well-deserved rest.

Frame 26

Four days later, you consider discharging Tamaya, since her blood pressure, temperature, and heart and respiratory rates have been within normal parameters for the past two days, and she has been eating well.

You make your way to her ward and greet her cheerfully.

"Good morning, Tamaya. How are you feeling today?"

She gives you a blank stare and mumbles "Okay, I guess. I feel fine". You note her apparent disinterest, and ask what's wrong.

"I still feel really tired and my joints hurt when I move," she says.

You acknowledge her concerns and proceed to examine her.

Both the general and systemic examinations reveal no abnormalities, and you inform Tamaya that she might be clinically fit to go home.

Frame 27

She looks at you with a furrowed brow and asks, "Are you sure? I still feel pretty horrible."

You tell her that you'll have a look at her most recent blood work, and let her know for sure.

Frame 28

The monitor shows that Tamaya's PCV and platelets have returned to low-normal levels, with the three most recent measurements showing an improving trend.

Her transaminases are following a downward trend towards normal as well.

You also notice an elevated IgM and mildly elevated IgG. A chest X-ray obtained earlier this morning shows no abnormalities.

Frame 29

What will you tell Tamaya as regards her discharge?

Choice Outcome Score Continues
She should stay for another 24 to 48 hours to monitor her antibody levels Incorrect 0 → Frame 30
She can be discharged later today, after a visit from the infectious diseases nurse for education regarding her condition Correct 1 → Frame 31
She should stay for inpatient physiotherapy until she regains her strength Incorrect 0 → Frame 32

Frame 30

You call the infectious diseases specialist to inquire about Tamaya's raised antibody levels and are cut short midway through your question.

"IgM and IgG antibodies develop in the patient's blood five to ten days after a primary dengue infection. As long as the criteria for discharge are met, she is safe to go home."

You make a mental note to go through these criteria after your shift today.

Frame 31

You explain to Tamaya that post dengue infection, listlessness, easy fatigability, and joint soreness are quite normal. Simple analgesia may be taken to relieve symptoms.

Tamaya smiles, relieved to know the reason for her persisting symptoms. You proceed to call an infectious diseases specialist nurse to visit her prior to discharge.

You say goodbye and make your way to see the other patients under your care, satisfied with a good outcome.

Well done!

The end

Frame 32

Tamaya understands that she has to stay a little longer, since she doesn't feel very good still.

You get a call from the infectious disease specialist that afternoon, just as you're about to present a case at a local conference.

He informs you that Tamaya is fit to be discharged and requests that you review your decision.

On your way back to the hospital, you go over the latest discharge criteria and realize that Tamaya is, in fact, fit for discharge.

Her persisting symptoms are part of the natural course of the disease and do not warrant continued hospital stay. You return to her ward.

Frame 33

You ask your team to prepare to defibrillate Tamaya.

However, the relevant nurse looks at you as if you'd attempted to shock her instead.

"But doctor!", she says, "this is clearly pulseless electrical activity due to the hypovolemia. Don't you want to correct that first?"

You realise that she is correct, and initiate aggressive fluid resuscitation.