Where you are:
FY2 in the Emergency Department.
Who the patient is:
15-year-old Samantha Green came to the clinic with a fever.
What you should do:
Talk to the patient, assess, and address her concerns
Malaria (Positive Findings):
- A high temperature, sweats and chills
- Headaches and feeling confused
- Feeling very tired and sleepy (especially in children)
- Feeling and being sick, tummy pain and diarrhoea
- Loss of appetite
- Muscle pains
- Yellow skin or whites of the eyes
- A sore throat, cough and difficulty breathing
- Cerebral Malaria – Impaired Conscious level, or seizures.
- Oliguria, acidotic breathing
- Haemoglobinuria - Dark urine
Presenting complaint (P1) (ODIPARA):
D: Hello I am one of the doctors in this Emergency department. You must be Samantha Green?
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 15.
D: So, Samantha, I can see that you have been having some fever?
P: Yes, doctor.
D: Tell me more about this fever (Open question)
D: When exactly did it start?
P: Well, doctor, it started 3 days ago. (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It comes and goes.
D: Have you measured it? (Intensity)
P: Yes, doctor, I have been measuring it, the last time I checked it was 39.7°C.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Anything that you think makes it better or worse? (Aggravating and relieving factors)
P: It just comes and goes on its own. I did try taking some paracetamol and that helps a little.
D: Anything else apart from the fever?
P: Yes, doctor, I have also been feeling a bit sick since this started and I get these body aches that are really bad. When I have this fever, I also get sweats and chills.
D: Tell me more about these problems, did they start with the fever?
P: Yes.
D: Anything else?
P: I also get these headaches since this has started.
Concern
D: Apart from this, is there anything else that’s worrying you?
P: No doctor, this is just what’s bothering me. It doesn’t seem to get better.
D.D’s Rule out
- Lower respiratory tract infection (Any cough, chest pain)
- Urinary tract infections (Any problems with the water works)
- Gastroenteritis (Any problems with your bowels)
- RED FLAGS : Meningitis/Encephalitis (Any neck stiffness, Rash, Problem with light, Any weakness anywhere in the body)
Past medical conditions (P2)
D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.
D.E.S.A:
Any smoking ?
What about alcohol?
M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.
D: Did you travel outside the UK in the past couple of weeks?
P: Yes, doctor, I went with my parents to South Africa 2 weeks ago, we came back 5 days ago. It was for my dad’s business.
D: Did you have any contact with anyone there, who was having a similar problem?
P: No doctor, I can’t remember having met anyone with a similar problem.
Anything else?
Expectations?
D: Do you have anything specific in mind that you are expecting from us?
P: I just went to feel better, doctor.
Examination:
- Observation (Check vitals)
- General Physical Examination: head-to-toe examination, pallor, jaundice.
- GCS assessment
- Abdominal Examination: Hepatomegaly and Splenomegaly
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea what is happening with me. I have never had anything like this happen to me before.
Suspected diagnosis:
D: So, Samantha, you told me that you have been having this fever and chills, and you have been feeling sick along with body pain for the past couple of days. Also you told me that you travelled recently to South Africa 2 weeks ago and through my examination, I did, indeed, notice that you are still running a fever. I suspect that you might have contracted an infection during your trip. I suspect it could be something like malaria but we will need to run some tests to find the exact cause.
P: Ok, doctor. So what can you do about it and what tests are you going to do?
Management:
-
Admit/Referral:
- Malaria is a medical emergency so the patient should be admitted in the hospital to be reviewed by a specialist.
-
Involve senior
-
Investigations:
- Routine blood investigations including full blood count, and inflammatory markers.
- Specific Investigations: Microscopy of thick and thin blood films (Gold Standard) – If first blood films are negative further blood testing to be done in 12-24 hours later. Antigen detection test.
-
Symptomatic:
- Painkillers
- Antipyretics
- Anti-sickness medication
- Hydration
DOs to prevent malaria.
- If you’re travelling to an area where malaria is found, get advice from a GP, nurse, pharmacist or travel clinic before you go.
- It’s best to do this at least 4 to 6 weeks before you travel, but you can still get advice at the last minute if you need to.
- Take any antimalarial medicine you’re prescribed – you usually need to start taking it a few days or weeks before you go, until a few weeks after you get back.
- Use insect repellent on your skin – make sure it’s 50% DEET-based.
- Sleep under mosquito nets treated with insecticide.
- Wear long-sleeved clothing and trousers to cover your arms and legs in the evening, when mosquitoes are most active.
-
Definitive management:
- Arrange immediate admission for specialist assessment and review if the patient is: Suspected to have severe or complicated malaria, a pregnant woman, a child or above 65 years.
- Urgently discuss all other people suspected of having malaria with an infectious disease specialist: People with non-falciparum malaria may be admitted or observed for at least 8 hours after starting anti-malarial therapy.
- Ensure that all cases of malaria have been notified to Public Health England.
- Medications to treat Malaria
- Artesunate.
- Artemisinin combination therapy (ACT) Atovaquone-proguanil.
- Quinine plus doxycycline.
- Primaquine.
-
Specialist: Discuss the case with infectious disease specialist
-
Complication:
- Severe anaemia: where red blood cells are unable to carry enough oxygen around the body, leading to drowsiness and weakness
- Cerebral malaria: in rare cases, the small blood vessels leading to the brain can become blocked, causing seizures, brain damage and coma
-
Safety net