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Mary Kyerewaa

Mary Kyerewaa, a 3-year-old girl, was admitted to the emergency ward after a sudden collapse at school, accompanied by a fever persisting for three days. Initial assessments indicated a high temperature of 38.9°C and a pulse of 148 bpm, with a possible diagnosis of malaria sepsis. Treatment plans included IV Artesunate, Cefuroxime, and monitoring vital signs, with a confirmed diagnosis of malaria on August 1, 2024.

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9 views3 pages

Mary Kyerewaa

Mary Kyerewaa, a 3-year-old girl, was admitted to the emergency ward after a sudden collapse at school, accompanied by a fever persisting for three days. Initial assessments indicated a high temperature of 38.9°C and a pulse of 148 bpm, with a possible diagnosis of malaria sepsis. Treatment plans included IV Artesunate, Cefuroxime, and monitoring vital signs, with a confirmed diagnosis of malaria on August 1, 2024.

Uploaded by

melchibaidoo
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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AKUA ABAKOMA CATHOLIC MEDICAL CENTRE

Outpatient Clinical History Report

Biodata
Patient name: MARY KYEREWAA

Date :
01-Aug-24
Hospital ID: 512/24
Age: 3
Gender: F

Vitals
Temperature Weight Pressure Pulse Height
38.9 *C 148 bpm

Notes
Chief Complaint- SUDDEN COLLAPSE IN SCHOOL
fever-3/7

HPC- A 3year old Toddler was rushed to the EMERGENCY WARD by her school teacher on account of sudden collapse in
school about 2hours ago . According to the mother, child started spiking temperature 3days ago of which she treated with
otc meds(syru pmol ) but symtoms persisted this before she left for school.

INITIAL INTERVENTIONS
IV LINE ACCESSED WITH 22G CANNULA
RECTAL DIAZEPAM 2.5MG STST AT 2:10PM AND SUPP PMOL 250MG STAT

ODQ: FEVER+,CHILLS+, RIGOR+, VOMITING-, STARTLING ATTACK+, COUGH+, RUNNING NOSE+, ABDOMINAL PAINS-, POOR
FEEDING+, DIARRHOEA-, DYSURIA-,

PMHX- MULTIPLE SEIZURES (4TIMES WITHIN THIS 7MONTHS PEERIOD

DRUG HX- SYRUP PMOL


ALLERGIES- NIL

O/E: Seen lying comfortably in bed sleeping, no signs of respiratory distress, not jaundiced, not pale, very warm to touch.

cns- consious and alert with GCS-15/15


CV- Regularly irregular pulse-148bpm
RS- Adequate air entry in all lung zones.

VITAL SIGNS
Respiration-
25cpm Spo2-96 %
PULSE-148
BPM TEMP-
38.9*C

INVESTIGATIONS
MPS-960P/UL

IMP- MALARIA SEPSIS?


CAUSE

PLAN-

Physician/ FRANC
AKUA ABAKOMA CATHOLIC MEDICAL CENTRE
Outpatient Clinical History Report
ADMIT TO CHILDRENS WARD
TO DO MPS

Physician/ FRANC
AKUA ABAKOMA CATHOLIC MEDICAL CENTRE
Outpatient Clinical History Report
IV ARTESUNATE 45MG 0,12,24HOURS
IV PMOL 225MG TID X 24
SYRUP MULTIVITE 10MLS DAILY X 10
INFUSION D5% 500MLS X 24
MONITOR VITALS 4HOURLY
IV CEFUROXIME 500MG TID X 24

Diagnoses
Diagnosis Date
MALARIA 01/08/2024

Medication
SEPSIS 01/08/2024
Date Drug Dosage OutCome Qty
01/08/2024 Artesunate Injection, 30 mg 45MG TID X24 Served 6
01/08/2024 Cefuroxime Injection, 750 mg 500MG TID X 4 Nill 0
01/08/2024 PARACETAMOL INFUSION 100ML 250MG TID X 2 Served 1
01/08/2024 Multivitamin Syrup 10MLS DAILY X Served 1
01/08/2024 Dextrose Infusion, 5% (500 mL) 500MLS X 24 Served 1
03/08/2024 Artemether + Lumefantrine Suspension, (Powder ForRec 20/120mg bd x 0
03/08/2024 Paracetamol Syrup, 120 mg/5 mL 225mg tds x 5 0
03/08/2024 Multivitamin Syrup 5mls tds x 5 0
03/08/2024 Ascorbic Acid Syrup 5mls tds x 5 0
03/08/2024 Cefuroxime Suspension, 125 mg/5 mL 225mg bd x 7 0

Lab Investigation
Procedures
Date Procedure
01/08/2024

Imaging

Additional Notes

Physician/ FRANC

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