malaria slide

1
GRAND ROUND PRESENTATION

• GROUP A3
• MEMBERS
• FREDERICK WILLBROD
• MARYCLAUDIA MIKA
• RENATUS MIHAYO
• EILEEN MICAH
• CHERYL MBILINYI
• FACILITATORS
• DR. CHRISTINE
• DR. MHINA

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PATIENTS PARTICULARS

• NAME MWANAHARUNA SEJA
• AGE 16 YEARS
• SEX FEMALE
• ADDRESS TEGETA MADALE
• TRIBE RANGI
• OCCUPATION STUDENT
• RELIGION MUSLIM
• MARITAL STATUS SINGLE
• EDUCATION LEVEL FORM ONE
• INFORMANT MOTHER/SISTER
• REFERRAL STATUS REFERRED MADALE DISPENSARY
• DATE OF ADMISSION 11/12/2023 DATE OF CLERKSHIP
  12/12/2023
• DAYS IN THE WARD 1 DAY
• NEXT OF KIN MOTHER

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CHIEF COMPLAINTS

• LOSS OF CONSCIOUSNESS 1/7

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HISTORY OF PRESENTING ILLNESS

• The patient has loss of consciousness for 1 day
  that was sudden on onset . She experienced
  dizziness as well as speaking irrelevant words
  prior the episode, there were no precipitating
  nor relieving factors. Following the episode the
  patient was unable to recall the events leading
  up to the loss of consciousness.
• However, the patient had no history of
  convulsion, blurred vision, tingling or numbness

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HISTORY OF PRESENT ILLNESS

• The LOC was preceded by headache for one week,
  that was gradual on onset and more marked on the
  frontal part. It was throbbing in nature and non-
  radiating. It was associated with dizziness,
  general body weakness and high grade fever. The
  headache was present throughout the day but more
  marked in the evening. It was not exacerbated by
  light and/or loud noise but relieved by taking
  Paracetamol.
• Prior to the LOC she had already taken her
  breakfast 2 hours before.

6
REVIEW OF THE OTHER SYSTEMS

• EENT (EARS, EYES, NOSE AND THROAT)
• No hx of ear pain , discharge or hearing loss
• No hx of eye pain, discharge or loss of eye sight
  
• No hx of nasal pain, discharge or bleeding, no
  loss of smell
• No hx of throat pain or painful swallowing
• RESPIRATORY SYSTEM
• No hx of chest pain
• No hx of difficulty in breathing
• No hx of cough
• No hx of wheezing

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• CARDIOVASCULAR SYSTEM
• No hx of central chest pain
• No hx of difficulty in breathing on lying flat
• No hx of awareness of heartbeats
• No hx of lower limb swelling
• GASTROINTESTINAL SYSTEM
• No hx of difficult or painful swallowing
• No hx of abdominal pain
• No hx of passage of loose, black or hard stool
• No hx of change in appetite

8

• UROGENITAL SYSTEM
• No hx of painful urination
• She reported hx of reduced urine output which was
  dark coca-cola like colour.
• No hx of increased frequency of urination at
  night
• No hx of vaginal discharge, itching nor rashes
• ENDOCRINE SYSTEM
• No hx of excessive sweating
• No hx of cold or heat intolerance
• No history of excessive thirst
• No hx of unexplained weight loss

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• MUSCULOSKELETAL SYSTEM
• No hx of joint/muscle pain and swelling
• HEMATOPOIETIC SYSTEM
• No hx of easy bruising
• No hx of bleeding tendencies
• DERMATOLOGICAL SYSTEM
• No hx of skin rashes, itching or hair loss

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• PAST MEDICAL HISTORY
• This is the patients first admission
• She had multiple outpatient visits due to UTI and
  was treated
• The patient has no history of chronic illnesses
  such as Diabetes mellitus, hypertension,
  Epilepsy, Sickle cell disease, HIV/AIDS
• The patient has no hx of head trauma
• The patient has no hx of surgeries
• The patient has no hx of blood transfusion
• The patient has no known food allergies
• The patient has no hx of drug allergies
• The patient has no hx of using traditional
  medication
• The patient has no hx of long term drug usage

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• GYNAECOLOGICAL HISTORY
• Menstrual history Attained menarche at the age
  of 13.
• Has a menstrual cycle of 30 days and last for
  about 5 days.
• She changes 3 pads per days, moderately soaked
  with blood with mild abdominal pain.
• No hx of contraceptive use

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• FAMILY HISTORY
• She is the third born among five children
• Other siblings are alive and well
• Parents are alive and well
• No hx of familial diseases such as diabetes,
  asthma, epilepsy and sickle cell disease
• There was no hx of sudden deaths in the family
• SOCIAL HISTORY
• She is a student at Kisarawe Secondary School
  (Form 1)
• No hx of alcohol use
• No hx of smoking cigarettes
• No hx of illicit drug use
• She lives in Kisarawe, the house is surrounded
  with tall grass and a lot of mosquitoes and is
  well ventilated.
• She uses mosquito net most of the time.
• She drinks boiled water

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• DIETARY HISTORY
• The patient eats three meals per day
• The patient takes
• Tea and cassava for breakfast(carbohydrates and
  fats)
• ugali with meat and vegetables for lunch
  (carbohydrates, proteins and vitamins)
• Rice with beans for dinner (Carbohydrates,
  proteins)
• The patient eats fruits such as mangoes, oranges
  and watermelons
• The patient drinks less than 1L of water per day
• The patients diet was satisfactory.
• The water intake is inadequate

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• SUMMARY 1
• M. S a 16 year old, female patient who presented
  with
• Loss of consciousness 1/7 preceded by headache
  for 1/52,
• General body weakness,
• Fever,
• Dizziness
• oliguria and cocacola dark urine
• She had no hx of convulsions,
• no hx of numbness and tingling sensation
• no hx of palpitations,
• no hx of blurred vision.
• She lives at Kisarawe in a house surrounded by
  long grasses and mosquitoes

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• CLINICAL DIAGNOSIS
• Complicated malaria
• Points for
• The patient lives in area with long grasses and a
  lot of mosquitoes
• Headache , fever, generalized body weakness, loss
  of consciousness
• Reduced urine output
• Differential diagnosis
• Dengue fever
• Point for headache , fever, general body
  weakness, loss of consciousness
• Point against The absence of a rash or bleeding
  diathesis
• Meningitis
• Point for headache , fever, general body
  weakness, loss of consciousness
• Point against no photophobia

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PHYSICAL EXAMINATION

• GENERAL EXAMINATION
• The patient was unconscious with GCS 7/15
  (E2V1M4), with a green cannula on her right
  cubital fossa for administering IV medications
  and a urinary catheter with a urine output of
  100mls
• She had
• Evenly distributed black colored hair,
• Was not pale , not jaundiced and not cyanosed
• Dry mucous membranes, no sunken eyes, skin pinch
  goes back normally
• Has normal ears with no discharges.
• No nasal blockage, no nasal discharge.
• No angular cheilitis, normal dental formula,
• no atrophic glossitis and no oral thrush

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• GENERAL EXAMINATION
• No finger clubbing, no koilonychia, no
  Leukonychia, no splinter hemorrhage, Normal
  capillary refill of less than 2 seconds, no
  palmar erythema, no Oslers nodes, no Janeway
  lesions ,no peripheral lymphadenopathy, no lower
  limb edema.
• VITALS
• Axillary temperature 38.1 C
• Blood pressure 123/74mmhg
• Respiratory Rate 22 breaths per minute
• Pulse Rate 90 bpm
• SpO2 98 on room air
• Comment Other parameters were normal but the
  patient was tachypneic and febrile

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SYSTEMIC EXAMINATION

• NERVOUS SYSTEM EXAMINATION
• Higher centres
• ? The patient was unconscious with a Glasgow coma
  score of 7/15 E2V1M4
• ?Memory, speech and orientation could not be
  tested.

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• Brain stem examination
• Cranial nerve examination
• CN I,CN III, IV ,V,VI,VIII,IX,X,XI could not be
  tested because the patient was unconscious.
• CN II Pupils reacted to light , visual field
  and visual acuity could not be tested.
• CN VII The patient had normal facial symmetry
  and could wrinkle her forehead thus CN VII was
  intact.

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• PERIPHERAL NERVOUS SYSTEM
• Motor examination

R.U.L L.U.L R.L.L L.L.L
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movements NIL NIL NIL NIL
Gait - - - -
Tone NORMAL NORMAL NORMAL NORMAL
Power 2/5 2/5 2/5 2/5

• Gait and coordination could not be examined
  because the patient was unconscious

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• 7. Reflexes

DEEP TENDON REFLEXES RIGHT SIDE LEFT SIDE
BICEPS REFLEX NORMAL NORMAL
TRICEPS REFLEX NORMAL NORMAL
PATELLA REFLEX NORMAL NORMAL
ACHILLES REFLEX NORMAL NORMAL
BABINSKI DOWNWARD DOWNWARD

• SUPERFICIAL REFLEXES Abdominal reflexes present.

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• Sensory system
• Posterior/Dorsal columns tract and Spinothalamic
  tract could not be tested
• Meningeal signs
• Kernigs sign was negative
• Brudzinskis sign was negative
• No neck stiffness

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• RESPIRATORY SYSTEM EXAMINATION
• Inspection
• No sputum cup, no oxygen mask or cylinder
• The chest was bilaterally symmetrical
• No surgical scars or traditional marks.
• There was symmetrical chest movement during
  respiration with a respiratory rate of 22 breaths
  per minute
• There was no use of accessory muscles in
  breathing
• Palpation
• There was no tenderness, no superficial palpable
  lymph nodes
• No swelling/mass
• The trachea was centrally located
• Apex beat palpable at the left fifth intercostal
  space midclavicular line
• Symmetrical chest expansion on both sides of the
  lungs
• Tactile fremitus could not be assessed

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• Percussion
• ? Both the lung fields were resonant on
  percussion
• Auscultation
• ?Normal vesicular breath sounds were heard in all
  the lung fields
• ?No added sounds such as wheezes, crackles.
• Vocal fremitus and whispering pectoriloquy could
  not be assessed

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• CARDIOVASCULAR SYSTEM EXAMINATION
• ? The capillary refill on the right hand was lt2
  seconds.
• ? The radial pulse of right hand was 90bpm
  regular rhythm, non-collapsing in nature, strong
  volume, symmetrical to peripheral pulses(
  radial-radial, radial - carotid and
  radial-femoral synchronicity), and the arterial
  walls were smooth.
• ? The Blood pressure 123/74 mmHg, heard at
  Korotkoff phase 1 and 5 in supine lying position.
  
• ? No visible pulsations on the neck.
• ? No jugular vein distension
• Jugular venous pressure was 7cmH20 (not elevated)
• Precordial examination
• Inspection
• ? No surgical scars or traditional marks.
• ? No precordial bulging
• ? No precordial hyperactivity

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• Palpation
• ? Apex beat felt at the left fifth intercostal
  space midclavicular, normal character.
• ? No palpable murmurs(thrills)
• ? No left parasternal heaving
• Auscultation
• ? Heart sounds S1 and S2 heard at the mitral,
  tricuspid, pulmonary and aortic areas.
• ? No murmurs were heard.
• ? No systolic clicks and opening snaps.
• ? The lung bases were clear.

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• GASTROINTESTINAL SYSTEM EXAMINATION
• PER ABDOMEN
• Inspection
• ? Distended abdomen in the suprapubic region.
• ? Inverted umbilicus.
• ? Symmetrical movement of the abdominal wall with
  respiration.
• ? No surgical scars or traditional marks.
• ? No spider naevi.
• ? No visible peristalsis.
• ? No prominent superficial veins.
• ? No visible pulsations.

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• Palpation
• On superficial palpation there was a palpable
  mass but not tender
• On deep palpation there was suprapubic tenderness
  
• Mass felt was firm, not mobile and had smooth
  borders
• The left kidney, spleen, right kidney and liver
  were not palpable.
• The liver span was 12 cm from the right subcostal
  margin
• Percussion
• ? Tympanic note on percussion
• Auscultation
• ? No vascular bruits were heard
• ? 12 bowel sounds per minute

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• SUMMARY 2
• Mwanaharuna Seja a 16 year old, female patient
  who presented with
• Loss of consciousness 1/7 preceded by headache
  for 1/52,
• General body weakness,
• Fever,
• Dizziness
• oliguria and cocacola dark urine
• She had no hx of convulsions, p. neuropathy,
  palpitation nor blurred vision
• She lives at Kisarawe in a house surrounded by
  long grasses and mosquitoes.
• O/E Unconcious GCS 7/15 (E2V1M4), Febrile
  (Tgt38.2), tachypnoeic (rr -22bpm), with a
  distended abdomen that was tender on the
  suprapubic area and reduced power of 2/5 on both
  upper and lower limbs.

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Clinical diagnosis from History and Physical
examination

• Complicated Malaria with AKI
• Points for
• The patient lives in area with long grasses and a
  lot of mosquitoes
• Headache , fever, generalized body weakness, loss
  of consciousness
• Reduced urine output (100mls in 12hrs)and dark
  coca-cola coloured urine

31

• Differential diagnosis
• Dengue fever
• Points for headache , fever, general body
  weakness
• Points against The absence of a rash or bleeding
  diathesis
• Meningitis
• Points for headache , fever, general body
  weakness
• Points against vomiting, negative kernings
  sign, negative Brudzinskis sign

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• 2. Pregnancy
• Points for Suprapubic distension
• Points against she is not sexually active
• 3. Urinary Tract Infection
• Points for- reduced urine output, dark coloured
  urine
• DDX Cystitis
• Points for Reduced urine output, abdominal
  distension

33

• INVESTIGATIONS

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Investigation to be done

• Baseline investigation
• FBP
• ESR
• CRP
• Acute phase proteins
• PT, PTT
• RBG
• BILIRUBIN TOTAL AND DIRECT

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Investigations to be done

• Specific Investigations
• MRDT
• B/S FOR MPS
• URINALYSIS
• RFT (UREA, CREATININE, URIC ACID, SERUM
  ELECTROLYTES)
• UPT
• PELVIC USS
• CSF ANALYSIS

36

• INVESTIGATIONS DONE BY THE PATIENT
• Malaria rapid diagnostic test- Tested positive
• Blood slide for parasites- 120mps/200wbc on
  11/12/2023
• UPT- NEGATIVE
• URINALYSIS- RBCs, 75hpf
• Renal Function Tests
• Serum Creatinine- 63.25umol/L (normal range 53-
  120umol/L) normal
• Blood Urea Nitrogen- 4.1 mmol/L (normal range
  2.5- 7.5 mmol/L) normal

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fbp
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TREATMENT IN THE WARD

• Sodium chloride IV solution (NS) 0.9 500mls
  bottle(s) given for 3 days
• IV paracetamol 1g tds
• Artesunate IV 120mg given on admission (time
  0hr), then at 12hrs and 24hrs
• After clearance of malaria parasites on BS
• The patient will be started on a complete course
  of 3days of Artemether lumefantrine (Alu)
• Furosemide 40mg tablets PO Twice a day 2days

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Progress in the ward

• The patient is still on IV artesunate and fluids
  ( but given cautiously to avoid fluid overload)
• Patient regained consciousness d3 in the ward and
  the GCS was 14/15 (E4V5M5)
• Control B/S was done after completion of 24hrs
  course of artesunate and showed 20mps
• Control renal functions were done and were normal
• Prognosis is good if patient adheres to
  medication and is properly hydrated
• Education on malaria prevention was also given to
  patient and her relatives