Identifying Information: A.O.

is a 28-year old male, African from Uganda, single, Roman Catholic, currently residing in Katipunan Avenue, Quezon City admitted for the first time at the Medical City on May 16 2013. Source and Reliability: Information was gathered from the patient, with 70% reliability. Chief Complaint: fever of two days duration History of Present Illness: Patient was apparently well until two days prior to admission, while staying in Metro Manila in his visit to the Philippines, when he started experiencing intermittent generalized headache, characterized as throbbing and heavy, 5/10 in severity, non-radiating. Patient subsequently developed undocumented fever (Tuesday, 2pm) and loss of appetite. Patient took paracetamol 500 mg/tab, one tablet three times a day which afforded some relief, as headache decreased to 1-2/10 in severity and fever temporarily lysed. No associated rashes, bleeding, changes in sensorium, abdominal pain, jaundice, arthralgia, myalgia, changes in bowel movement, nausea or vomiting. No consult at this time. Headache recurred until one day prior to admission when he noted worsening of headache, now noted to be 7-8/10 in severity. Patient took paracetamol 500 mg/tab, 1 tablet three times a day, with no relief of headache. No associated fever, rashes, bleeding, changes in sensorium, abdominal pain, jaundice, arthralgia, myalgia, changes in bowel movement, nausea or vomiting. No consult at this time. Morning of admission, still with headache, patient noted that undocumented fever recurred, now accompanied with chills and increased sweating, occurring at 12 mn (Thursday) and 6 pm (Thursday). He subsequently developed intermittent epigastric pain, characterized as fullness, 2/10 in severity, non-radiating. Patient took paracetamol 500 mg/tab, one tablet three times a day, with no relief. Patient also developed loose watery stools, 3 episodes, amounting to approximately cup per episode, non-bloody, non-mucoid, non-foul smelling. No associated jaundice, rashes nausea or vomiting. Due to persistence of fever, patient decided to seek consult at The Medical City, hence this admission. Review of Systems: Skin. No masses. No pruritus. No sores. No itching. No dryness. No color changes. HEENT. Eyes: No eye discharge. No vision problems. Ears: No hearing loss, no tinnitus. Nose: No colds. Oral cavity: No dry mouth. No gum bleeding. Throat: No hoarseness. Neck. No masses. No pain. Pulmonary. No cough. No hemoptysis. No difficulty of breathing. Cardiovascular. No chest pain. No palpitations. No orthopnea. Gastrointestinal. See HPI. Urinary. No dysuria. No frequency. No hematuria. No nocturia. No change in color of urine. Musculoskeletal. No difficulty ambulating. Neurologic. No sensory loss. No motor weakness. Hematologic. No easy bruising. Endocrine. No increased sweating. No temperature intolerance. Past Medical History: Childhood Illnesses G6PD Deficiency Patient advised to avoid eating fava beans. Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Adult Illnesses Medical: Malaria Admitted in a local hospital in Uganda in 2005 due to 3 day history of fever, epigastric pain, and generalized body malaise. Malarial smear was positive for plasmodium falciparum. Given chloroquine phosphate, unrecalled dosage, for 10 days. Patient noted improved condition after intake of medication. No adverse reactions with medication taken. Malaria Admitted in a local hospital in Uganda in 2009 due to 2 day history of fever, epigastric pain, and loss of appetite. Malarial smear was positive for plasmodium falciparum. Given sulfamethoxypyrazine + pyrimethamine, 2 tablets only. Patient noted resolution of symptoms after intake of medications. No previous history of eye correction, no pneumonia, no tuberculosis, no cardiac disease, no hypertension, no dyslipidemia, no diabetes, no asthma, no kidney disease, no cancer. Surgical: No previous surgical operations. Psychiatric: No previous psychiatric consultation. No history of blood transfusions. No previous hospitalizations. No previous history of trauma. No known allergies to food and drugs. Immunization History: Unrecalled childhood vaccinations. Vaccinated for yellow fever on May 2013. Family History: The Family of A.O. May 17, 2013

Father

Mother

Brother, 36

Sister, 32

AO, 28

Brother, 26

Sister, 22

No family history of hypertension, myocardial infaction, cardiovascular disease, stroke, asthma, cancer, allergies, diabetes.

Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Personal and Social History: Patient was born and raised in Uganda, and currently works as a part-time teacher and missionary in Uganda. Patient is a non-smoker, occasional alcohol drinker (1 bottle of Nile Special beer during special occasions), and denies drug use. Patient is currently travelling in the Philippines to attend a religious conference. Patient arrived in the Philippines on May 13, 2013 and attended a religious conference. On his second day in Manila (May 14, 2013), he attended a birthday party in Quezon City. Patient has been staying in Metro Manila during his time in the Philippines. He does not have any pets. Sexual History Patient denies any sexual encounter in the past. Exercise Patient engages in 30 minutes of exercise (jogging), three times a week. Diet and Nutrition 24 hour food recall: Breakfast: Cereal and a glass of milk Lunch: Sweet potatoes, nuts and green leafy vegetables Dinner: Cassava, nuts and green leafy vegetables Patient does not have any food preferences. Stakeholders Analysis: Stakeholder Role

Mother

Primary caregiver

Stand on the Issue Ally

Intensity of Stand

Degree of Influence

Insight

Father

Primary breadwinner

Ally

Brothers and sisters

Social support

Ally

Moderate Mother occasionally checks up on the health status of the patient Moderate Father occasionally checks up on the health status of the patient Moderate Siblings occasionally check up on the health status of the patient

Low Decision making regarding patients health concerns is largely decided by the patient alone. Moderate Mother occasionally checks up on the health status of the patient Moderate Mother occasionally checks up on the health status of the patient

Low Mother lacks awareness of the possible severity of the patients condition Low Father lacks awareness of the possible severity of the patients condition Low Siblings lack awareness of the possible severity of the patients condition

Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Physical Examination: General Patient appears awake, alert, comfortable. Vital Signs Heart rate: 93 beats per minute and regular, Respiratory rate: 17 breaths per minute, BP: 110/80 (right brachial artery, seated), Temperature 36.8 C. Pain scale: 5/10 Anthropometrics Height: 163 cm Weight: 60 kg BMI: 22.6 Skin Dark skin. Palms warm. Good skin turgor. No clubbing, no cyanosis. No rashes. HEENT Ophthalmologic Gross Exam Right Anicteric sclera, pink palpebral conjunctiva. Left Anicteric sclera, pink palpebral conjunctiva.

Ears. Bilateral ear canals are clear. Good cone of light noted on bilateral tympanic membrane. Head turns towards voice. Weber midline. AC > BC. Nose. Mucosa pink, septum is midline. Sinuses are nontender. Mouth. Moist lips. Moist tongue. Oral mucosa pink. No mucosal ulcers noted. Tongue midline, pharynx without exudates. Neck. Supple neck, trachea midline. Thyroid lobes not felt. Lymph Nodes: No cervical lymphadenopathy, no axillary lymphadenopathy. Pulmonary Thorax symmetric with good excursion. Equal tactile and vocal fremiti. Percussion of lung fields showed resonant notes. Auscultation revealed clear breath sounds. No crackles, no wheezes, no rhonchi.

Cardiovascular Adynamic precordium. No heaves, no thrills. Apex beat is palpable at the 5th intercostal space left midclavicular line. Good S1, S2; no S3 nor S4. No murmurs. Back and Spine Straight back and spine. No scoliosis. Gastrointestinal Abdomen is flat. Bowel sounds are normoactive (five per minute). Liver span is 9 cm, right midclavicular line. Edge is smooth, palpable 1 cm below right subcostal margin. Direct tenderness noted on the epigastric area. No rebound tenderness. No splenomegaly. No masses felt. Negative costovertebral angle tenderness. Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Extremities Warm and without edema. Calves supple, non-tender. Peripheral Vascular Full and equal pulses. No edema, nor stasis pigmentation, nor ulcers. Capillary refill time is less than two seconds. Musculoskeletal Good range of motion in hands, wrists, elbows, shoulders, spine, hips, and ankles. Neurologic Mental Status. Patient was awake, alert, relaxed, and fluent throughout the entire interview. He was appropriately dressed for age. Mood: His mood was neutral. Affect: Patient is euthymic. Speech: Patient speaks in a normal rate, soft tone with clear speech. Thought processes: Thoughts are coherent with no flight of ideas, no tangentiality and no circumstantiality. Thought content: No delusions, nor hallucinations. Orientation: Oriented to person, place and time. Attention: intact Memory: Immediate, recent and remote memory intact. Visuospatial function: intact Intellectual ability: roughly average Language: naming, writing, reading intact Judgment: good Insight: good Total score for MMSE: 30/30 Cranial Nerves I: can smell II: Visual Acuity Visual fields Fundoscopy

20/20 Full by confrontation ROR intact, clear media, Disc margins sharp, without hemorrhages, nor exudates.

20/20 Full by confrontation ROR intact, clear media, Disc margins sharp, without hemorrhages, nor exudates.

III, IV, VI: Pupils 2-3 mm symmetric, equally reactive to light. Full and intact extraocular movements. Accommodation reflex intact. V: light touch, pain and temperature sensation intact on all three divisions of the trigeminal nerve. Patient is able to chew. (+) corneal reflex VII: No facial asymmetry. Facial movements intact. Taste for anterior 2/3 of the tongue is intact. VIII: Acuity good to whispered voice. Weber midline. AC > BC. IX, X: No hoarseness, gag reflex intact, soft palate rises symmetrically. XI: Able to shrug shoulders and turn head from side to side. XII: Tongue midline. No tongue atrophy, no fasciculations. Motor: Left upper extremity Right upper extremity 5/5 5/5 Left lower extremity Right lower extremity Strength 5/5 5/5 Strength Sensory: Left upper extremity Right upper extremity Sensation 100% 100% Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Left lower extremity Right lower extremity Sensation 100% 100% Light touch, position sense, vibration and stereognosis intact. Romberg negative. Cerebellar: Rapid alternating movements, point-to-point movements intact. Reflexes: Biceps Triceps Brachioradialis Patellar Achilles Plantar Left 2+ 2+ 2+ 2+ 2+ 2+ Right 2+ 2+ 2+ 2+ 2+ 2+ Meningeal Signs; No tonic neck rigidity. (-) Kernigs sign, (-) Brudzinski sign. Course in the Wards: At the ER, patient was seen and examined and was worked up as a possible case of systemic viral illness, r/o dengue, r/o malaria. Laboratories were requested including CBC, urinalysis, fecalysis, which all showed normal results. Malarial peripheral blood smear requested was positive for plasmodium falciparum ring forms (see Appendix B). Venoclysis was started with plain NSS 1L for 8 hours and Ibuprofen 200 mg capsule was given as antipyretic. Patient was also referred to surgery service for evaluation of epigastric pain, with assessment showing a non-surgical abdomen at this time. Patient was subsequently admitted and the following laboratory examinations were requested: creatinine, ALT, AST, Blood culture in 2 sites once febrile, Dengue NS1, Baseline CBG, and Chest xray, which all showed normal results. G6PD testing revealed decreased enzyme activity (see Appendix A). IV fluid was subsequently shifted to PNSS 1L x 100 ml/hour. At the floors, patient was started with Artemether-Lumefantrine (Coartem) 4 tablets per orem initial dose then 4 tablets per orem 8 hours later, then 4 tablets per orem 2x a day for 2 days. Daily quantitative malarial smear was also requested. He was also given Paracetamol 500mg PO every 4 hours for fever and headache and NSAIDs were restricted for the patient since they may precipitate prerenal azotemia to ischemic acute renal failure in patients with malaria. On his 2nd hospital day, patient was noted to be comfortable but still complained of mild headache with decreased appetite. Patient was noted to be afebrile with stable vital signs. Malarial counts were noted to be decreased in comparison to initial counts obtained in the ER (see appendix G). On his 3rd hospital day, patient was noted to feel better, afebrile, with no subjective complaints. No malaria was seen in peripheral smears, hence patient was recommended for discharge. Patient was sent home improved, stable and prescribed with Coartem 4 tabs last dose at 4 am the next day. Appendix A: G6PD testing (May 17, 2013) performed to confirm initial findings Result: 9.31 U / g Hb Reference Value: Newborns : > 13.22 U / g Hb 1-6 months: > 12.22 U / g Hb >6 months: 10.01 U / g Hb Interpretation: Positive for G6PD Deficiency Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan Primitive Reflexes: (-) Babinski reflex

Appendix B: Malarial Smear (May 17, 2013) Result: Positive for plasmodium falciparum ring forms (560/ul) Appendix C: Malarial Antigen Kit Result: Positive Appendix D (Table 1): Complete Blood Count (May 17, 2013) Parameter Result Reference Range Hemoglobin 155 g/L 135-170 g/L Hematocrit 0.45 0.40-0.54 Red Blood Cell 5.44 X 1012/L 4.60-6.20 X 1012/L White Blood Cell 4.80 X 109/L 4.50-10.00 X 109/L Mean Corpuscular Hemoglobin 29 pg 27-31 pg Mean Corpuscular Hemoglobin Concentration 0.34 0.32-0.36 Mean Cell Volume 83 fl 80-96 fl RDW 12.3 11.5-16.0 Thromobocyte (Platelet) 140 X 109/L 140-440 X 109/L Differential Count Neutrophil 0.71 Lymphocyte 0.20 Monocyte 0.08 Eosinophil 0.01 Erythrocyte Morphology: Normocytic, Normochromic 0.56-0.66 0.22-0.40 0.04-0.08 0.01-0.04

Appendix E (Table 2): Urinalysis (May 17, 2013) Parameter Result Color LIGHT YELLOW Transparency CLEAR Reaction 8.0 Specific Gravity 1.010 Erythrocytes NEGATIVE Protein NEGATIVE Glucose Leukocytes Ketones Urobilinogen Bilirubin Nitrites NEGATIVE NEGATIVE NEGATIVE NORMAL NEGATIVE NEGATIVE

Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Test Result Reference Range Red Blood Cell 0 / hpf (0 2) White Blood Cell 0 / hpf (0 2) Epithelial Cells 5 /hpf (0 2) Casts 0 / lpf (0 3) Bacteria 1 /hpf (0 20) Appendix F: Liver Function Tests (May17, 2013) Test SGPT (ALT) SGOT (AST) Creatinine Result 27 U/L 30 U/L 0.93 mg/dl Reference Range (0 55) (5 - 34) (0.70 1.30)

Appendix G: Repeat Malarial Smear (May 18, 2013) Positive for plasmodium falciparum ring forms (160/ul) Appendix H: Adult Nutrition Assessment Form Diet Prescription: 1800 kcal /day (60-20-20) Regular Diet Salient Features: History o 28 year old Ugandan male o Fever of two day duration o Associated symptoms: intermittent generalized headache, intermittent epigastric pain and 3 episodes of loose watery stools o PMH: G6PD Deficiency and Malaria (2009) o No jaundice, no bleeding Physical Examination o Stable vital signs o (+) direct tenderness, epigastric area o No hepatomegaly, no splenomegaly o Normal neurologic examination

Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan

Differential Diagnosis Acute gastroenteritis, no signs of dehydration Viral Hepatitis

Dengue Fever, without warning signs Meningitis

Likely 3 episodes of loose watery stools, with intermittent epigastric pain, (+) direct tenderness, epigastric area, can present with fever Fever, with intermittent epigastric pain, (+) direct tenderness, epigastric area, can present with generalized headache and diarrhea (+) fever, epigastric pain, (+) direct tenderness, epigastric area, can present with diarrhea and headache Presented with headache, fever

Less Likely Need fecalysis and stool testing to rule out

Need workup to rule out

Need workup to rule out Usually does not present with abdominal pain or diarrhea No tonic neck rigidity. (-) Brudzinski sign. (-) Kernigs sign Needs lumbar puncture to rule out definitively Patients with encephalitis usually have changes in behavior. Usually does not present with abdominal pain or diarrhea. No tonic neck rigidity. (-) Brudzinski sign. (-) Kernigs sign No vomiting, no changes in sensorium

Viral Encephalitis

Presented with headache, fever

Brain abscess Malaria

Presented with headache, fever

Presented with fever, intermittent epigastric pain, (+) direct tenderness, epigastric area, can present with generalized headache and diarrhea (+) history of malaria Primary Working Impression: Uncomplicated Malaria r/o drug-resistant type G6PD Deficiency

Criteria for Uncomplicated Malaria Symptomatic infection with malaria parasitaemia without signs of severity and/or evidence of vital organ dysfunction. No CNS involvement, no ARDS, no low blood pressure, no kidney failure, no metabolic acidosis

Enrik John Aguila. Maria Carissa Alejandro. John Kevin Alonzo. Charl Andrew Bautista. Leinelle Bernardino. Ramon Alberto Ramos. Chelsea Samson. Joel Josef Soller. Ralph Tagalog. Harold Nathan Tan