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CASE PRESENTATION

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

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CASE 1

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General information

• A female, 29 years old
• Occupation: housewife
• Address: Naxu village

Vangvieng district Vientiane province

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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

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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

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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

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Problem lists

• Fever
• Headache
• Myalgia.
• Low back pain
• Urine burning and painful
• Costo vertebral angle tenderness positive

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Differential diagnosis

• 1. Acute pyelonephritis
• 2. Rickettsial disease

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Labs results

16/12/16 20/12/16

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Result Lab

• Serology rickettsial

negative

• U/S : normal

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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

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26/12/16

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Final diagnosis

• Septicemia due to E.Coli ESBL*

*Extended Spectrum Beta-Lactamases

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Treatment (con’t)

• ff ceftriaxone and switch to
• Amikacin 250mg 1flx2/days

For 7days switch to oral medicine

• Nitrofurantoin 1tablet 4time /days

for 7days

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CASE 2

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General information

• A male, 20 years old
• Occupation: worker
• Address: Napho village

Hinphun district khammoun province

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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

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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

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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

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Physical examination

▪ Heart : JVD -, regular rhythm, no murmur.

▪ Abdomen : soft, No Ascites, No mass, No hepato- splenomegaly ▪ lung: clear no crepitation ▪ Neuro : power hyper reflex both leg Neck stiffness : Positive Kernig sign positive Brudzinski’s positive ▪ Skins: no PPE, no pale, no rash, No pitting edema

4/5 4/5 4/5 3/5

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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

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Differential diagnosis

• 1. Meningitis
• 2. Brain abscess
• 3. Encephalitis

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Labs results

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CSF result

Albumins 32 Glucose 29 HIV TEST: negative

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CXR

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CT scan Brain

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Treatment

At ICU:

• Ceftriaxone 2g every 12h
• Dexamethazone 8mg every 6h
• Omepalzole
• Perfalgan

Treat for 4days the patient get better so refer to IDA

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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

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Final diagnosis

• Patient still have fever
• CSF result : High Lymphocyte count

Low Glucose

Tuberculosis Meningitis

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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

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CASE 3

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General information

• A male, 64 years old
• Occupation: retired
• Address: Nakhunnoi village

Nasaythong district Vientiane Capital

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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

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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

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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

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Physical examination

▪ Heart : JVD -, regular rhythm, no murmur.

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

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Problem lists

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

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Differential diagnosis

• 1. Disseminated Melioidosis
• 2. Septic artritis
• 3. Pneumonia

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Labs results

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Labs results

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CXR

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U/S

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X-ray col felmural

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Hemoculture

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Uro culture

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Pus culture

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Final Diagnosis

• Disseminated Melioidosis
• DM type II

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Treatment

• At ICU:
• Ceftazidime 2g every 8h
• Blood transfusion
• Omeprazole
• Insulin R
• Treat at ICUA 19th days after that refer patient

to IDA continuous treat

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Thanks for your attention

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