Laporan Jaga RSPAD Malaria (Azlan Sain)

1. Morning report:
MALARIA
Azlan Sain
RESOURCE PERSON:
Dr. dr. Soroy Lardo SpPD, FINASIM
DEPARTMENT OF INTERNAL MEDICINE
RS KEPRESIDENAN RSPAD GATOT SOEBROTO
JULI 2017

2. IDENTITY
Name : Tn. HFA
DOB/Age : February 20th 1989/ 28 years old
Religion : Moslem
Marital Status : Married
Address : Asr. Yon-23 Grup 2 Kopassus Semplak Bogor
Medical Record : 858699
Admission : July 10th 2017 01.30 AM
Ward : PU Lantai 3

3. CHIEF COMPLAINT
High fever with chilled since 4 days before hospital admission

4. HISTORY OF PRESENT ILLNESS
 Five days before admission to RSPAD, patient felt dizzy and muscular
aching, but fever was denied
 Four days before admission, patient felt fever, repeated at interval 2 days
(once fever once not), fever last throughout the day, followed by chills,
sweating, headache, and muscular aching and weakness. History of fever at
particular time of a day is denied, highest temperature recorded might reach
up to 39◦C
 Patient also complained feeling nauseous during meal without history of
vomiting. Decreased of appetite was denied.
 No history of cough, nor shortness of breath, normal micturition and
defecation. No abdominal pain. No nosebleed, no bleeding of gums

5. HISTORY OF PRESENT ILLNESS
 Patient has experienced military exercise in Merauke about 2 months.
After 1 month running, patient experienced fever and felt not so good
in his body. Then, he had sought medical assistance to RST Merauke
(July 06th, 2017), ran blood tests and was diagnosed with Malaria
Tropicana (based on his story, but the data was not brought to
Jakarta).
 He said that he was injected with Artesunat injection there with 2x60
mg doses for 2 days, and Primakuin 3 tablets single dose but he didn't
get the next dose of Artesunat injection because he already must be
evacuated to Jakarta for further treatment.
 Patient was evacuated to Jakarta in July 8th, 2017

6. HISTORY OF PAST ILLNESS
• Patient was already diagnosed with malaria four times before:
• 1st attack was diagnosed with Malaria Tertiana
• 2nd attack was diagnosed with Malaria Tropicana
• 3rd attack was diagnosed with Mix Tropicana-Tertiana
• 4th attack was diagnosed with Malaria Tertiana
and this time is his fifth attack of Malaria
• Three previous Malaria before were got when he was in duty about one year
in Wembi, Papua, and the last one was got in Jakarta a week after he came
back from his duty from Papua
• He has history of Tuberculosis in 2014, taking routine medication for 6
months, and had been declared cured by the physician
• He also has history of fistula anal operation in 2014
• Hypertension and type II diabetes were denied

7. HISTORY OF FAMILY ILLNESS AND
SOCIAL ECONOMIC STATUS
• HISTORY OF FAMILY ILLNESS
• Patient's father has a hypertension
• No diabetes, nor heart disease in his family
• No one has ever had malaria in patient's family
• SOCIAL AND ECONOMIC STATUS
• Patient is second child from 3 siblings in his family
• Patient sometimes smoke 1-2 cigarettes per day, sometimes not at all
• During exercise in Merauke, patient stated that the workload was so high so he
hadn't enough time to got a rest
• Patient works as Kopassus soldier
• Patient has been married for 1 year, now his wife is in fifth month pregnancy
and live in Malang
• Health financing with BPJS Dinas
• Intake of vitamin and another supplement are denied
• No history of chemoprophylaxis of malaria

8. PHYSICAL EXAMINATION
(ON PRESENTATION)
Vital Signs
BP : 132/79 mmHg
HR : 81x/min, regular, adequate
RR : 22x/min, torakal
T : 36.3◦C
BW : 66 kg
Height : 171cm
IMT : 22.7 kg/m2 (normoweight)
General Status
• Conciousness: Compos
mentis
• General condition: mildly
ill

9. PHYSICAL EXAMINATION
• Skin : within normal limit
• Head : normocephal, no coated tongue
• Hair : greyish black hair, hair can’t be plucked easily
• Eyes : no pale conjunctiva, no icteric sclera
• Neck : no lymph node enlargement, JVP 5-2 cmH2O
Lung
Inspection : symmetrical on insipiration and expiration
Palpation : symmetrical fremitus
Percution : sonor on both lungs
Auscultation : vesicular, no wheezing, no rales
Heart
Inspection : ictus cordis can't be located
Palpation : ictus cordis palpable on 1 finger medial to linea
midclavicularis sinistra, thrill (-), heaving (-), lifting (-)
Percussion : heart borders within normal limit
Auscultation : regular S1 S2, no murmur, no gallop

10. PHYSICAL EXAMINATION
Abdomen
Inspection : flat stomach
Palpation : supple, no pain on palpation, no liver or spleen
enlargement
Percussion : no shifting dullness
Auscultation : bowel sound normal
Extremities
CRT<2”, warm lower extremities, no edema, rumple leed test (-)

11. LABORATORY FINDING
Jenis Pemeriksaan Nilai Rujukan 09/07/2017
HEMATOLOGI
Hemoglobin 13,0-18,0 g/dL 13.4
Hematokrit 40-52 % 37
Eritrosit 4,3-6,0 x 106/L 4.8
Leukosit 4.800-10.800/L 5140
Trombosit 150.000-400.000/L 98000
MCV 80-96 fL 76
MCH 27-32 pg 28
MCHC 32-36 g/dL 37
KIMIA KLINIK
SGOT < 35 U/L 14
SGPT < 40 U/L 18
Ureum 20-50 mg/dL 22
Creatinin 0.5-1.5 mg/dL 0.9
Laboratory result (09/07/2017) in emergency admission

12. LABORATORY FINDING
Jenis Pemeriksaan Nilai Rujukan 09/07/2017
Glukosa Darah (Sewaktu) 70-140 mg/dL 110
Natrium 135-147 mmol/L 136
Kalium 3.5-5.0 mmol/L 3.3
Klorida 95-105 mmol/L 103
IMMUNOSEROLOGY
Anti Dengue IgM Negatif Negatif
Anti Dengue IgG Negatif Negatif

13. Jenis Pemeriksaan Nilai Rujukan 09/07/2017
Malaria
I. Plasmodium Falciparum Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
II. Plasmodium Vivax Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Ditemukan 12/200 Leukosit
Ditemukan 180/200 Leukosit
Ditemukan 36/200 Leukosit
III. Plasmodium Malariae Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
IV. Plasmodium Ovale Negatif Tidak Ditemukan
• Tropozoit
• Schizont
• Gametosit
Negatif
Negatif
Negatif
Tidak Ditemukan
Tidak Ditemukan
Tidak Ditemukan
LABORATORY FINDING

14. RESUME
 28 year-old-male patient with chief complaint of high fever with
chills since 4 days before hospital admission. Febris with intermittent
pattern, repeated at interval 2 days, followed by headache, and
muscular aching and weakness.
 Patient already had malaria four times before, and had history of
visiting malaria endemic areas. Patient was treated as Malaria
Tropicana in Merauke and had injection Artesunat and Primaquine
per oral 1x3 tab single dose.
 Physical examination revealed within normal limit. From laboratory
findings, patient is known to have Plasmodium Vivax from
microscopic examination and trombocytopenia.

15. PROBLEM
MALARIA FEVER (TERTIANA)

16. Problem Assessment Plan of Care Plan
Malaria
Tertiana
Based on:
History :
Fever, repeated at interval 2 days,
intermittent pattern (once fever once
not), and followed by chills, sweating,
headache, and muscular aching and
weakness
Patient was diagnosed and treated as
Malaria Tropicana in Merauke and
had injection Artesunat and
Primaquine per oral single dose.
Already had Malaria four times
before
Laboratory findings:
Plasmodium Vivax (+), Ditemukan
12/200 Leukosit (tropozoit)
Ditemukan 180/200 Leukosit
(schizont)
Ditemukan 36/200 Leukosit
(gametosit)
Plasmodium Falciparum (-)
Trombocytopenia
Target:
Clinical
improvement
Malaria cured
Diagnostic:
Thin and thick blood film for
evaluate therapy post treatment
Therapy :
- IVFD NaCl 0.9% 500 cc/8
hour
- Paracetamol 3x500mg
- DHP 1x4 tab (3 days)
- Primakuin 1x1 tab (14 days)
- Ranitidine inj. 2x1 amp
- Antacida syr 3xC1
- Domperidone 3x1 tab
Education :
─ Increase endurance by
eating lots of vegetables,
fruits, drink a lot of water,
and have enough time to get
rest
─ Take routine and regular
medication
─ Use mosquito net when
sleep

17. MALARIA
• Malaria is caused by the protozoan parasite Plasmodium, with an
incubation period of 7 days or longer
• Human malaria is caused by four different species of
Plasmodium: P. falciparum, P. malariae, P. ovale and P. vivax.
• The malaria parasite is transmitted by female Anopheles
mosquitoes
• P. vivax and P. ovale can remain dormant in the liver. Relapses
caused by these persistent liver forms (“hypnozoites”) may
appear months, and rarely several years, after exposure
• People who are immunosuppressed and elderly travellers to
endemic areas are particularly at risk of severe disease
• Falciparum malaria may be fatal, other Plasmodium species are
rarely life-threatening

18. Fever Pattern in Malaria

19. MALARIA VIVAX (PATHOGENESIS)

20. DIAGNOSIS
• Anamnesis
– Main complaints: fever (based on pattern), chills, sweating and may be
accompanied by headache, nausea, vomiting, diarrhea and muscle aches
– Visiting history and overnight 1 - 4 weeks to the region of endemic
malaria
– The history of living in malaria endemic areas
– History of sick malaria and take malaria drug
• Physical Examination
– Fever (measurement with thermometer more than 37.5 ° C)
– Pale conjunctiva (anemia)
– Enlargement of spleen (splenomegali) and liver (hepatomegaly) can be
found

21. DIAGNOSIS
• Laboratory Finding
– Microscopic examination (Blood and thin blood test (SD) examination to
determine:
• 1. The presence or absence of malaria parasites (positive or negative)
• 2. Species and stadium plasmodium
• 3. Parasite density:
– Semi kuantitatif
» Negatif (tidak ditemukan parasit dalam 100 LPB/Iapangan
pandang besar)
» positif 1 (ditemukan 1 -10 parasit dalam 100 LPB)
» positif 2 (ditemukan 11 -100 parasit dalam 100 LPB)
» positif 3 (ditemukan 1 -10 parasit dalam 1 LPB)
» positif 4 (ditemukan >10 parasit dalam 1 LPB)
– Kuantitatif (Jumlah parasit dihitung per mikro liter darah pada
sediaan darah tebal (leukosit) atau sediaan darah tipis (eritrosit)
– Rapid Diagnostic Test (RDT)

23. TREATMENT
• ACT (Artemisinin
Combination Therapy)
– Artesunate - Amodiaquin
– Dihydroartemisinin -
Piperaquin
The drug dose for malaria vivax
is similar to malaria falciparum,
where the difference is the
administration of medication
primakuin in malaria vivax is
given for 14 days with dose
0.25 mg/kgBB

24. PROGNOSIS
• Ad vitam : Bonam
• Ad functionam : Bonam
• Ad sanationam : Dubia ad bonam

25. Thank You