grand round 2

1
GRAND ROUND PRESENTATION

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

2
PATIENTS PARTICULARS

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

3
CHIEF COMPLAINTS

• HEADACHE 1/52
• LOSS OF CONSCIOUSNESS 1/7

4
HISTORY OF PRESENT ILLNESS

• The patient presented with 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 (
  which was also gradual on onset, NO SPECIFIC
  PERIODICITY, no aggravating factors, and was not
  relieved by medication such as paracetamol). The
  headache was present throughout the day but more
  marked in the evening. It was not exacerbated by
  light and loud noise but relieved by taking
  Paracetamol.

5

• The patient also presented with loss of
  consciousness for 1 day that was sudden on onset
  and lasted for 6 hours. She experienced dizziness
  as well as speaking irrelevant words prior the
  episode, there were no precipitating, aggravating
  and relieving factors. Following the episode, the
  patient was confused and 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

6
REVIEW OF THE OTHER SYSTEMS

• EENT (EARS, EYES, NOSE AND THROAT)
• No hx of pain
• No hx of abnormal discharge
• No hx of hearing loss
• RESPIRATORY SYSTEM
• No hx of chest pain
• No hx of difficulty in breathing
• No hx of cough
• No hx of wheezing

7

• CARDIOVASCULAR SYSTEM
• No hx of 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 difficulty in swallowing
• No hx of painful swallowing
• No hx of abdominal pain
• No hx of passage of loose stool
• No hx of passage of hard stool
• No hx of passage of black stool
• No hx of change in appetite

8

• UROGENITAL SYSTEM
• No hx of painful urination
• No hx of reduced or absence of urine output
• No hx of excessive urine output
• No hx of increased frequency of urination at
  night
• No hx of vaginal discharge
• No hx of vaginal itching and rashes
• No history of painful sexual intercourse

9

• ENDOCRINE SYSTEM
• No hx of excessive sweating
• No hx of cold intolerance
• No hx of heat intolerance
• No history of excessive thirst
• No hx of unexplained weight loss
• MUSCULOSKELETAL SYSTEM
• No hx of joint pain
• No hx of joint swelling
• HEMATOPOIETIC SYSTEM
• No hx of easy bruising
• No hx of bleeding tendencies

10

• PAST MEDICAL HISTORY
• This is the patients first admission
• The patient has no hx of outpatient visits
• The patient has no history of chronic illnesses
  such as Diabetes mellitus, hypertension,
  Epilepsy, Sickle cell disease, HIV/AIDS and
  Systemic Lupus erythematosus
• 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 or drug allergies

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• GYNAECOLOGIC AND OBSTETRIC HISTORY

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• FAMILY HISTORY
• The patient was the third born among five
  children who are alive and well
• Her father and mother are alive and well
• There was no hx of familial diseases such as
  diabetes, asthma, epilepsy and sickle cell
  disease in both matrilineal and patrilineal side
• There was no hx of sudden deaths in the family
• SOCIAL HISTORY
• No hx of alchohol use
• No hx of smoking cigarettes
• No hx of illicit drug use
• She lives in a malaria endemic area, the house is
  surrounded with tall grass and is well
  ventilated.
• She uses insecticide treated nets
• 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.

14

• DRUG HISTORY
• The patient has no hx of using traditional
  medication
• The patient has no hx of long term drug usage
• The patient has hx of using over the counter
  medication such as paracetamol

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• SUMMARY 1
• Ive just presented to you M. S a 16 year old,
  female patient who presented with
• Headache, Loss of consciousness, General body
  weakness, Fever, Dizziness, has hx of living in a
  malaria endemic region. The patient had no hx of
  convulsions, no hx of numbness and tingling, no
  hx of awareness of heartbeats, no hx of blurred
  vision.
• CLINICAL DIAGNOSIS
• Complicated malaria
• Points for
• The patient lives in a malaria endemic region
• Headache , fever, generalized body weakness, loss
  of consciousness

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• Differential diagnosis
• Dengue fever
• Point for headache , fever, general body
  weakness
• Point against loss of consciousness
• Bacterial meningitis
• Point for headache , fever, general body
  weakness
• Point against vomiting, neck pain