MEDICAL
SUMMARY
D.M /52YRS/ MALE
Diagnosis: Cerebral Malaria
complicated by multi organ failure
History and Presentation:
Above name patient was admitted semi conscious, initially suspected to
be CVA but Urgent CT did not how any evidence of stroke. He was said to have
slumped 12 hrs prior to presentation and was taken to Garki hospitals by
passerby. No other history available
He is not a known hypertensive, diabetic
Temp: 37.6C. PR: 105BPM
Currently GCS: E-4, M-4 V- 1
Pupils- 3mm sluggishly reactive
Chest: Acidotic breath, Appears slightly labored breathing
RR -21cpm Spo2: 99%
on O2 facemask.
Transmitted sounds.
Abdomen: FMR, no palpable organomegly
Urinary- deep amber concentrated urine 200mls in the last 3 hrs
Laboratory investigations on admission
FBC: wbc- 2.24, pcv- 39.80, plt- 12
EUCR: Na- 141.2, k- 5.47, ur- 131.9, Cr- 3.93mg/dl
MP: +++ seen
FLP: hdl- 6.02
Serology: HbsAg- reactive
Clotting profile: inr- 1.0, apt- 29.1, pt- 13.4
RBS: 5.4mmol/L
ABD USS: suggests
a.
?
fatty liver r/o ? hepatitis
b. Splenomegaly
c.
Cystitis
? UTI
Diagnosis: Cerebral Malaria
complicated by multi organ failure
Management plan:
·
Monitor
neurovital signs closely
·
Monitor
Input/Output
·
IVF
N/S 1L alternate with 5% D/S 8hrly
·
IV
ceftriaxone 1g 12hrly
·
IV
metronidazole 500mg 8hrly
·
Tabs
keppra 2g stat, then 1g bd.
GASTROENTEROLOGY
REVIEW 22/7/23
A 52 year old police officer, who was brought
in unconscious for about 12 hours duration. Patient was noticed to have lapsed
into unconsciousness and was taked to a sister hospital from where he was
referred here.
Detailed history
would not be ascertained.
On examination:
patient was noticed to be jaundiced with grunting respiration, moderate pedal
edema.
GCS: 10/15, no lateralizing
sign.
Abdomen: nil of
note.
Assessment: toxic
hepatopathy r/o hepatitis B viral infection
Plan:
1.
Repeat
LFT
2. 5 panel test for hepatitis B
3. IVF 10% D/W 1L 8hrly x 24hrs
then, 500mls 5% D/W 8hrly
4. IV frusemide 20mg
5. Tab spironolactone 100mg daily
6. In the event of bleeding, GXM
fresh whole blood
7.
Glucose
monitoring.
HAEMATOLOGY
REVIEW 22/7/23
Thanks for asking
me to see this 52 year old male who had slumped 48hrs ago. He was noticed to
have thrombocytopenia, mild anemia, and leukopenia. No bleeding from any
orifice. Most history not available as he resides alone in Abuja.
Other lab results
noted. HbsAg positive. PT and PTTK are normal.
O/E: unconscious,
oxygen mask, afebrile, nil purpura.
Ass: pancytopenia
? 2ry to HBV infection.
PLAN:
1.
Urinalysis,
HbsAg core antigen test, blood film to be reviewed by hematologist.
2.
Withhold
any antiplatelets, to be reviewed with blood film result
Blood
film report:
a.
Red
blood cell: normocytic, normochromic, few target cells, burr cells. Majority of
red blood cells have inclusion of malaria parasite.
b. White blood cell: slightly
reduced on film with neutrophilia
c.
Platelets:
reduced on film, few larger foons.
Impression:
significant high malaria parasitemia suggestive of cerebral malaria.
UPDATE
23/7/23
Hematology review
noted.
Patient was
commenced on IV artesunate 120mg and has received 2 doses. Patient has not
produced enough amount of urine.
Severely icteric
and pale. Constantly having hiccups.
Ass: cerebral
malaria with background multi-organ failure
Plan:
1.
To
transfuse with 2 units of blood
2.
For
hemodialysis
UPDATE
24/7/23
A case of black
water fever currently complicated by cerebral malaria (deeply unconscious) and
AKI( scanty coke coloured urine). He made only 50mls of urine in the last 24hrs
despite receiving 5 liters of fluid and high dose lasix.
Plan:
1.
Repeat
EUCR
2. Refer patient for hemodialysis.
3.
IV
10% calcium gluconate 10mls stat.
Kindly revert to us for clarifications
where necessary.
Yours Sincerely,
Dr. Ukandu Chinedu
For Team Wellington Clinics Abuja