• IAL , 43 / Iban /Female • Address: Rh Takin Pasai Bon • Date of Admission : 21/11/2010 • Time : 0755 hrs • Chief complaint of : Giddiness, on wheelchair • Triage category : G1 Seen by AMO • 0804 hrs • Giddiness x 3 days,fever x3 days • Neckache,retrosternum pain.loose stool,gen body weakness • No SOB, • O/E – weak on wheelchair • BP 120/70mmHg , PR 89 T 36.9 C • GCS 15/15 , spo2 100% • Plan – FBC,BUSE ,BFMP and for MO review Seen by HO • 0900 hrs • History of fever with chills and rigors since 19/11/2010. • Diarhoea since yesterday, reduce oral intake. • Assoc with headache,myalgia,arthralgia. • Took PCM 6.00 am today • Denied any SOB,skin rashes ,bleeding tendency/vomiting/abd pain. • No history of fogging,dengue ill contact. • PMH –known HPT and DM on treatment. • Pink , hydration good. • CVS DNM, lung equal air entry. • Abdomen soft , non tender and no organomegally, no pedal edema. • CRT < 2 sec. HGT 16.6 mmol/L • Hess test positive. • Body weight 80 kg. • Plan : – ECG Sinus rhythm,no ischemic changes – T.stemetil 2 tab stat. – Sc actrapid 4u stat. 0930 hrs. – UFEME,ABG. – Patient kept at waiting area . • Investigation result – FBC – 13.0/2800/27,000/36% – BUSE- 131/4.4/96/12.4 – BFMP- negative – ABG- pH 7.398,po2 95.3 , pCO2 22.9 , BE -9.2,HCO3 17.0 – UFEME-ketone negative progress • Pt complaint of epigastric pain at 12.15 noon • Given IV Ranitidine 50 mg stat. • Case referred to Medical MO oncall • Assessment given as – AGE with mild renal impairment • Plan – Admit Female Medical Ward – For CXR on way up. – For IV Drip, – PT/PTT,LFT,GSH,Creat. • SN FMW informed at 1215 hrs. • THANK YOU