HAEMATOLOGY WARD

CASES' PRESENTATION
MONDAY, 26TH FEBRUARY 2024
WARD CASES
• WARD STATE FROM FRIDAY(23/02/24)
• 3 patients
• 0 discharges
• 0 mortalities
• 2 new admissions
L.A
• 40 YRS OLD
• DAY 2 ON ADMISSION
CHIEF COMPLAINT(S)
• DIZZINESS, PALPITATIONS- A WEEK
HISTORY OF PRESENTING COMPLAINT
• PATIENT IS NOT KNOWN TO HAVE ANY CHRONIC ILLNESSES
AND WAS WELL UNTIL A WEEK PRIOR TO PRESENATION
WHEN SHE EXPERIENCED DIZZINESS AND PALPITAIONS
WHICH HAVE WORSENED SINCE ONSET. THESE WERE
ASSOCIATED WITH SOME EASY FATIGUABILITY. A DAY PRIOR
TO PRESENTATION AT KBTH, SHE SUSTAINED A FALL AS A
RESULT OF THE DIZZINESS AND HAD A LACERATION AT THE
CHIN. SHE PRESENTED TO RIDGE BHOSPITAL WHERE SOME
SHE WAS ASSESSED AND INVESTIGATIONS REVEALED SHE
WAS ANEMIC FOR WHICH SHE WAS TRANSFUSED 2 UNITS OF
BLOOD AND SUBSEQUENTLY REFERRED TO KBTH FOR
FURTHER MGT
FURTHER QUESTIONING
• FEVER-, CHILLS-, NIGHT SWEATS-, WEIGHT LOSS+,
ANOREXIA+, GUM BLEEDING+, EPISTAXIS-, HEMATURIA-,
MELENA-, HEMATEMESIS-, EASY BRUISING-, DYSPNEA-,
ORTHOPNEA-, PND-, COUGH-, PEDAL EDEMA-,
AXILLARY/INGUINAL/CERVICAL SWELLING-, ABD.
DISTENSION-, OLIGURIA-
PAST MEDICAL/SURGICAL HISTORY
• NO HX OF CHRONIC DX
• NO PREVIOUS SURGERIES
• TRANSFUSED 2 UNITS OF BLOOD PRIOR TO PRESENTATION
AT KBTH
DRUG HISTORY
• NO KNOWN FOOD/DRUG ALLERGIES
• NO USE OF HERBAL MEDICATIONS
FAMILY HISTORY
• NO KNOWN FAMILY HISTORY OF CHRONIC DISEASE
• NO KNOWN HISTORY OF SIMILAR PRESENTATION IN
FAMILY
SOCIAL HISTORY
• MARRIED
• LIVES AT ASYLUM DOWN WITH HUSBAND AND CHILDREN
• TRADER
• NHIS+
• ACCEPTS BLOOD TRANSFUSIONS
• ALCOHOL-
• SMOKING-
EXAMINATION
• GENERAL EXAM- MIDDLE. AGED WOMAN, LOOKED
ACUTELY ILL, P+++, J-, AFEBRILE, ACYANOSED, HYDRATION
SATISFACTORY, BIPEDAL EDEMA-,
LYMPHADENOPATHY; HAD A LACERATION ON THE CHIN
• CVS- PR-82BPM, RGV, JVP NOT RAISED, HIS&II+, M-
• RESP- RR-20CPM, SPO2 ON RA-98-99%, CHEST CLINICALLY
CLEAR
• ABD- FULL, MWR, SOFT, NON-TENDER-, L+(8 CM BELOW RT
SUBCOSTAL MARGIN, NON-TENDER, NO BRUIT), S+(5 CM
BELOW LT SUBCOSTAL MARGIN), 2K-, BOWEL SOUNDS+
EXAMINATION
• CNS-CONSCIOUS AND ALERT, NO FOCAL NEUROLOGICAL
DEFICITS
PROBLEMS
• HEPATOSPLENOMEGALY
• SYMPTOMATIC ANEMIA
• BLEEDING GUMS
• LACERATIONS FROM A FALL
INVESTIGATIONS
• FBC (23/02/24):
HB 3.3, MCV 85.8, MCH 30.3, WBC 257.65, NUET 3.86, LYMPH
120.40, MONO 133. 27, PLT 13

• LFT(10/12/23)
TOTAL BIL- 21.8 (3.0-22.0),DIRECT BIL-8.2, (0.0-5.0),AST-20 (14-
36),ALT-16 (<35), ALP-76(38-126), GGT-46(12-43), TOTAL
PROTEIN - 82 (63-82),ALBUMIN 40(35-50)
INVESTIGATIONS
• BUE/CR(23/02/24)
NA-139(135-150), K-4.1(3.5-5.5), CL-107(95-110), UREA(SI)-
9(2-7), CR(SI)-109(62-106), eGFR-63

• LDH(23/02/24)
735(MEN, <248, WOMEN<247)

• URIC ACID(23/02/24)
453 WOMEN [155 - 357]
INVESTIGATIONS
• RETROSCREEN(23/02/24)
NON-REACTIVE

• HBsAG(23/02/24)
NON-REACTIVE

• HEP C(23/02/24)
NON-REACTIVE
INVESTIGATIONS
• ABD.PELVIC SCAN(07/02/24)
• THE LIVER IS ENLARGED AND HOMOGENEOUS IN ECHOPATTERN
WITH A SMOOTH SURFACE AND SHARP EDGE. IT MEASURES 19.7
CM. NO FOCAL LESIONS SEEN. THERE IS NO INTRA- OR EXTRA
HEPATO-BILIARY DUCT DILATATION SEEN.
• GALLBLADDER IS NORMALLY OUTLINED WITH NORMAL WALL
THICKNESS. NO INTRALUMINAL PATHOLOGY NOTED.
• BOTH KIDNEYS ARE NORMAL IN SIZES AND SHOW GOOD
CORTICOMEDULLARY AND SINUS DIFFERENTIATION. THE RIGHT AND
LEFT KIDNEYS MEASURE [10.9X3.8] CM AND [9.9X3.8] CM
RESPECTIVELY. NO HYDRONEPHROSIS NO CALCULUS OR MASS
NOTED.
• THE SPLEEN IS ENLARGED AND HOMOGENEOUS IN ECHOPATTERN
MEASURING 14.8CM.
INVESTIGATIONS
• NO INTRA-ABDOMINAL MASS OR LYMPHADENOPATHY NOTED.
• THE UTERUS IS AVERAGE IN SIZE MEASURING [7.8X5.1X6.4]CM
WITH UNIFORM ENDOMETRIAL STRIPE THICKNESS. THE CERVIX
IS NORMAL.
• BOTH OVARIES ARE UNREMARKABLE.
• BOTH ADNEXA ARE NORMAL.
• THERE IS NO FREE FLUID NOTED IN THE POUCH OF DOUGLAS.
• THE URINARY BLADDER IS NORMAL IN WALL THICKNESS WITH
CATHETER BALLOON INSITU. NO INTRALUMINAL
PATHOLOGY NOTED.
• IMPRESSION: HEPATOSPLENOMEGALY.
DIAGNOSIS
• ?ACUTE LYMPHOBLASTIC LEUKEMIA
L.A- CURRENT ASSESSMENT
• C/O- DIZZINESS(IMPROVED SINCE ONSET)

• GENERAL EXAM- MIDDLE. AGED WOMAN, LOOKED ACUTELY ILL, P+++,

J-, AFEBRILE, ACYANOSED, HYDRATION SATISFACTORY, BIPEDAL
EDEMA-, LYMPHADENOPATHY; HAD A LACERATION ON THE CHIN

• CVS- PR-82BPM, RGV, JVP NOT RAISED, HIS&II+, M-

• RESP- RR-20CPM, SPO2 ON RA-98-99%, CHEST CLINICALLY CLEAR

• ABD- FULL, MWR, SOFT, NON-TENDER-, L+(8 CM BELOW

RT SUBCOSTAL MARGIN, NON-TENDER, NO BRUIT), S+(5 CM BELOW LT
SUBCOSTAL MARGIN), 2K-, BOWEL SOUNDS+
L.A- CURRENT MEDICATIONS
• ALLOPURINOL 300MG OD
• IV AMOKSICLAV 1G TDS X 5 DAYS
• IV N/S 500MG BD
• TB DICLOFENAC 75MG BD X 1 WEEK
• TB PREDNISOLONE 60MG OD
• TB OMEPRAZOLE 20MG BD
UPDATES
• TRANSFUSED 6 UNITS OF PLATELET CONC. ON DAY 0 OF
ADMISSION
• HAS BEEN TRANSFUSED 2 UNITS OF BLOOD SO FAR
• TO GET TED STOCKINGS
E.O
• 60YRS
• DAY 1 ON ADMISSION
CHIEF COMPLAINT
• LOW BACK PAIN
HISTORY OF PRESENTING COMPLAINT
• PATIENT HAS NO KNOWN CHRONIC CONDITIONS AND WAS
WELL UNTIL ABOUT A MONTH AGO WHEN HE STARTED
EXPERIENCING SHARP PAIN OF SUDDEN ONSET IN HIS
LOWER BACK AND HIPS WHILST WORKING (CARRYING A
SACK OF COCOA). HE USED SOME HERBAL MEDICATIONS
BUT PAIN DID NOT RESOLVE AND HENCE REPORTED TO A
PERIPHERAL FACILITY WHERE HE WAS GIVEN ANALGESICS
AND DISCHARGED HOME.
HISTORY OF PRESENTING COMPLAINT
• THE PAIN STILL PERSISTED AND AFFECTED HIS MOBILITY.
HE HAD TO USE A WALKING AID (CRUTCHES). ABOUT A
WEEK AGO, THE PAIN WORSENED AND IMPAIRED MOBILITY
COMPLETELY WHICH LEFT HIM BEDRIDDEN. HE REPORTED
TO THE ABOVE REFERRAL CENTRE WHERE SOME
LABS WERE RUN AND AN XRAY DONE SHOWED BILATERAL
FEMORAL NECK FRACTURES HENCE HE WAS REFERRED
HERE FOR FURTHER MANAGEMEN
FURTHER QUESTIONING
• FEVER-, CHILLS-, LOSS OF APPETITE-, HEADACHE-,
PALPITATIONS-, DIZZINESS-, EASY FATIGUABILITY-, NO
BLEEDING EPISODES, CHRONIC COUGH-, NIGHT SWEATS-,
WEIGHT LOSS+, NUMBNESS IN BOTH LEGS-, ABDOMINAL
PAIN-, CONSTIPATION+ (LAST TIME WAS 8 DAYS AGO),
NAUSEA-, VOMITING-, GENERALIZED WEAKNESS-,
OLIGURIA-, FOAMY URINE-, EARLY MORNING FACIAL
PUFFINESS-, PEDAL EDEMA-,
PAST MEDICAL HISTORY
• NO HISTORY OF CHRONIC DISEASE I.E HTN-, DM-, ASTHMA-
• NO RECENT ADMISSIONS,
• NO PREVIOUS SURGERIES/TRANSFUSIONS
DRUG HISTORY
• HAEMATINICS+, PAINKILLERS+
• HERBAL MEDS+ (WHEN CONDITION STARTED)
• NO KNOWN FOOD OR DRUG ALLERGIES
FAMILY HISTORY
• NO KNOWN FAMILY HISTORY OF CHRONIC DISEASE I.E
HTN-, DM-, ASTHMA-, SCD-
• NO HISTORY OF SIMILAR PRESENTATION IN FAMILY
SOCIAL HISTORY
• PURCHASING CLERK (SELLS COCOA), USED TO WORK AT A
SAW MILL FACTORY FOR 10YRS,
• MARRIED WITH 4 CHILDREN
• LIVES AT AKYEM ODA IN THE EASTERN REGION WITH
FAMILY
• ALCOHOL-, SMOKING-,
• NHIS+
• ACCEPTS BLOOD TRANSFUSION
EXAMINATION FINDINGS
• GENERALEXAM- MIDDLE-AGED MALE, LOOKS STABLE,
NOT IN OBVIOUS RESPIRATORY DISTRESS, P++, J-, AFEBRILE
(36.0*C), HYDRATION FAIR, BIPEDAL EDEMA-

• CVS: PR - 82BPM, RGV, BP - 118/66MMHG, HS 1 & 2 PRESENT,

APEX IS IN THE 6LICS MCL, JVP NOT RAISED, NO MURMURS

• RESP: RR - 18CPM, SPO2 - 95% ON RA,AE REDUCED ON RT,

MIDDLE TO LOWER ZONES ON LEFT, BS VESICULAR,
COARSE CREPS IN LOWER ZONES ON THE LEFT
EXAMINATION FINDINGS
• ABD: FULL, MWR, NON-TENDER, NO ORGANS PALPABLE, LIVER-
(SPAN ~9CM), BOWEL SOUNDS PRESENT AND NORMAL

• CNS: CONSCIOUS AND ALERT, COMMUNICATING, ORIENTED IN TPP

INVESTIGATIONS
INVESTIGATIONS DONE (AT REFERRAL CENTRE):

• SERUM CA (22/02/24): 3.51 (H)

• TPSA (22/02/24): 0.41

• XRAY OF THE HIP AND PROXIMAL FEMUR: OSTEOPENIC
CHANGES SEEN, BILATERAL FEMORAL NECK FRACTURE
INVESTIGATIONS
• INVESTIGATIONS DONE HERE (23/02/24):
• FBC
HB 7.0, MCV 72.0, MCH 21.8 (L), MCHC 30.3 (L), WBC 5.24, NEUT#
2.58, LYM# 2.22, PLT 157

• BUE/CR
• NA 138,, K 3.7, CL 103,UREA 11.2,CR 144,EGFR 51

• LFT: TOTAL BIL 5.5, DIRECT BIL 3.0, AST 22, ALT 15, ALP 53, GGT
38, TOTAL PROTEIN 109, ALBUMIN 31
• CALCIUM
TOTAL CA 3.46(H), ADJUSTED CA 3.64, ALBUMIN 31

• PHOSPHORUS
0.87

• HBA1C:6.1%

• CRP:REACTIVE (6.9MG/L)
INVESTIGATIONS
• CXR(23/02/24)
• BILATERAL OPACIFICATIONS IN ALL ZONES
DIAGNOSIS
• SUSPECTED MULTIPLE MYELOMA WITH
1. PATHOLOGICAL FRACTURES(BILATERAL FEMORAL NECK
FRACTURES)
2.HYPERCALCEMIA

• BILATERAL PNEUMONIA
CURRENT MEDICATIONS
• IV AMOKSIKLAV 1.2G TDS
• TB AZITHROMYCIN 500MG OD X 3/7
• IV DEXAMETHASONE 40MG DLYX 4/7
• TB OMEPRAZOLE 20MG BDS X 4/7
• IV PMOL 1G TDS
• IV NEFOPAM 20MG TDS
• TB APIXABAN 2.5MG DLY

• RECEIVED STAT DOSE OF IV ZOLEDRONIC ACID 3.5MG

UPDATES
• AWAITING OTHER REQUESTED INVESTIGATIONS I.E BLOOD
FILM COMMENT, SERUM PROTEIN ELECTROPHORESIS AND
FREE LIGHT CHAINS, URINE R/E, URIC ACID, LDH, VIRAL
SCREEN(HEP B, HCV, RETROSCREEN, ABD SCAN
• SEEN BY ORTHOPAEDIC SURGEONS
PLAN
• PLAN IS TO TRANSFUSE 3 UNITS OF CRCs(1 UNIT EACH DAY)
F. S
• 67YRS
• DAY 6 ON ADMISSION
CHIEF COMPLAINT
• WAIST PAINS OF 2/12,
• INABILITY TO WALK FOR 1 MONTH
HISTORY OF PRESENTING
COMPLAINTS
• PT IS A KNOWN HPT WHO PRESENTED TO US ON 7/02/ 24
WITH THE ABOVE COMPLAINTS.
• SHE WAS IN HER USUAL STATE OF HEALTH UNTIL 2MONTHS
AGO PRIOR TO PRESENTATION WHEN SHE STARTED
EXPERIENCING SEVERE WAIST PAINS WHICH LATER
PROGRESSED TO INABILITY TO WALK.
• SHE PRESENTED TO A PERIPHERAL HOSPITAL WHERE SHE
WAS TRANSFUSED WITH 2 UNITS OF BLOOD AND THEN
REFERRED HERE FOR FURTHER MANAGEMENT.
HISTORY OF PRESENTING COMPLAINT
CT.
• AT HEMATOLOGY, SERIES OF LABS WERE REQUESTED
INCLUDING SPEP AND SFLIC.
• PATIENT WAS PUT ON PANADOL 1G 6HRLY, ORAL MORPHINE
10MG TDS, LACTULOSE 15MLS BD.
• SHE WAS REFERRED TO RADIOTHERAPY ON ACCOUNT OF
THE LESION SEEN ON THE LUMBOSACRAL MRI AND THEN
SCHEDULED TO SEE US ON 21/02/24.
HISTORY OF PRESENTING
COMPLAINTS CT.
• PATIENT HAS BEEN IN THIS STATE UNTIL MONDAY WHEN
SHE PRESENTED TO THE ER WITH DYSPNOEA WHERE
DIAGNOSIS OF LEFT LOBAR PNEUMONIA COMPLICATED BY
PARAPNEUMONIC EFFUSION WAS MADE.
FURTHER QUESTIONING
• BONE PAIN+, DYSPNOE+, EASY FATIQUABILITY+,
DYPNOAE+, NO DIZZINESS OR BLEEDING EPISODES,
WEAKNESS+ BOTH LOWR LIMBS 3/12, IMMOBILITY+,
FEVER+, ABD PAINS+
PAST MEDICAL HISTORY
• HPTN ( 6YRS AGO), DM-, ASTHMA-, SCDX-, PREVIOUS
TRANSFUSION+, PREVIOUS SURGERY+.
DRUG HISTORY
• LISNOPRIL, PREGABALINE, DORETA.

• NO KNOWN DRUG ALERGIES

FAMILY HISTORY
• NIL OF NOTE
SOCIAL HISTORY
• A TRADER (COSMETICS), LIVES AT LAPAZ, ALCOHOL-,
SMOKING-, NHIS
EXAMINATION
• AN ELDERLY WOMAN WHO LOOKS CHRONICALLY ILL, P++, J-, HYDRATION IS
FAIR, HAS BILATERAL PITTING EDMA UP TO THE MID CHIN

• CVS:P-94BPM, BP-125/67MMHG, S1+, 2+, M0

• RESP: SPO2 96%ON RA, AE REDUCED BILATERALLY, CREPS HEARD IN THE

LEFT LOWER ZONE ANTERIORLY, POSTERIOR EXAMINATION NOT DONE OA PT
BEING UNABLE TO SIT UP OR TURN

• ABD: FULL, MWR, SOFT, NON-TENDER, L-, S-, 2K-

• CNS: GCS 15/15, CONSCIOUS AND COMMUNICATING

INVESTIGATIONS
• LUMBOSACRAL SPINE MRI( 24/01/24)):
• T11 AND L5 ABNORMAL T1 HYPOINTENSEAND T2 HYPERINTENSE SIGNAL
THAT DOES NOT SUPPRESS ON STIR SEQUENCE WITH COLLAPSE OF
THESE VERTEBRAL BODIES AND ASSOCIATED ANTERIOR THECA
INDENTATION AT THE L5/S1. DDX MALIGNANT NEOPLASM (MULTIPLE
MYELOMA/ METASTASIS)
• BILATERAL LIGAMENTA FLAVA HYPERTROPHY CAUSING MODERATE-
SEVERE NEURAL FORAMINA NARROWING WITH NERVE ROOT
COMPRESSION AT L5/S1
• COLLAPSE OF VERTEBRAL BODIES AND ASSOCIATED THECA IDENTATION
AS WELL AS BILATERAL FLARA HYPERTROPHY CAUSING MODERATE TO
SEVERE NEURAL FORAMINA NARROWING WITH NERVE ROOT
COMPRESSION AT L5/S1.
INVESTIGATION
• BUE/CR (7/02/24):
• NA+ 142(135-150), K+ 2.9(3.5-5.5), CL- 10195-110), UREA 11.8(2-
7), CR- 205(62-106), EGFR 25
• BUE(19/02/24):
• NA-129(135-150), K-2.9(3.5-5.5), CL-96(95-110), UR-15.2(2-7), CR-
170(62-106), EGFR-31
• BUE/CR(23/02/24)
• NA-133(135-150), K-2.6(3.5-5.5), CL-101(95-110), UREA(SI)-11(2-
7), CR(SI)-129(62-106), eGFR-43
INVESTIGATION
• FBC (29/01/23)
• HB-7, WBC 12.40, PLT 134
• FBC(14/02/24):
• HB 6.8, WBC- 9.99, PLT -111
• FBC(19/02/24):
• HB-4.9(11-18), MCV-90.3(65-97.5), MCH-29.2(27-32), WBC-
15.64(4.5-9.5), NEUT#-13.71(2-7), LYM#1.20(1-3), PLT-131(150-450)
• FBC(21/02/24):
• HB 8. 1, WBC 11.24, NUET8.11, PLT 141
INVESTIGATIONS
• BMA (14/02/24)AGRANULAR HAEMODILUTED, NOT SUITABLE FOR COMMENT.

• LFT(19/02/14):
• TOT. BIL.-7.1(3-22), DIRECT-4.3(0-5), AST-48(14-36), ALT-32(<35), ALP-105(38-126),
GGT-95(12-43), TOT. PRO.-71(63-82), ALB-30(35-50)

• ECG(19/02/24):
• SINUS TACHYCARDIA, HR- 115, LOW QRS VOLTAGE IN AVF

• CHEST X-RAY(19/02/24):
• BILATERAL PATCHY OPACIFICATIONS, MILD LEFT PLEURAL EFFUSION
INVESTIGATIONS
• SPEP(21/02/24):
• S. TOTAL PROTEIN 88, S- ALBUMIN- 31, ALBUMIN SERUM 22, ALPLA 1 GLOBULIN 4,
ALPHA 2 GLOBULIN 6, BETA 1 GLOBULIN 4, BETA 2 GLOBULIN 1, GAMMA GLOBULIN
5, M COMPONENT 46

• SFLC( 21/02/24): S KAPPA FREE LIGHT CHAINS 20,S LAMDA FREE LIGHT CHAINS 339,
KAPPA/ LAMDA RATIO 0.06, LAMDA/KAPPA RATIO 16.95

• HBA1C(23/02/24)
• 6.9%

• CALCIUM(23/02/24)
• TOTAL CALCIUM- 2.55(2.12-2.62), ADJ. CA-2.81, ALBUMIN-2.7(3.5-5.0)
DIAGNOSIS
• 1.MULTIPLE MYELOMA WITH BILATERAL PNEUMONIA
COMPLICATED BY PARAPNEUMONIC EFFUSION

• 2.KNOWN HYPERTENSIVE
CURRENT MEDICATIONS
• IV LEVOFLOXACIN 750MG DAILY
• TAB AZITHROMYCIN
• ORAL MORPHINE 10MG QID
• TB METFORMIN 500MG BD
• SLOW K 600MG TDS
• SC UFH 5000IU BD
CURRENT ASSESMENT
• C/O: PALPITATIONS

• ODQ- DYSPNEA-, ORTHOPNEA-, LOW BACK PAIN+

(IMPROVED FROM BEFORE), CONSTIPATION+(IMPROVED, 3
STOOL), ABDOMINAL PAIN-
• O/E: AN ELDERLY WOMAN WHO LOOKS CHRONICALLY ILL,
P++,J-, WARM TO TOUCH(TEMP-38. 5C), HYDRATION IS FAIR,
HAS BILATERAL PITTING EDEMA UP TO THE MID SHIN
• CVS:P-127BPM, BP-157/84MMHG, HS1+, 2+, M-
• RESP: RR-23CPM, SPO2 96%ON RA, AE REDUCED
BILATERALLY, CREPS HEARD IN THE LEFT LOWER ZONE
ANTERIORLY, POSTERIOR EXAMINATION NOT DONE OA PT
BEING UNABLE TO SIT UP OR TURN
• ABD: FULL, MWR, SOFT, NON-TENDER, L-, S-, 2K-
• CNS: GCS 15/15, CONSCIOUS AND COMMUNICATING
• RBS(25/02/24)- 13.6 MMOL/L
UPDATES
• HAD RECEIVED 4 DOSES OF DEXAMETHASONE

• HAS HAD 2 SESSIONS OF RADIOTHERAPY

• YET TO REPEAT BMA
• -INPUT/OUTPUT MONITORING PROPERLY CHARTED
PLAN
• - TO STOP LACTULOSE
• - TO HOLD SUPP. DUCOLEX 10MG FOR TODAY
• - TO HOLD IV CLINDAMYCIN
• - TO SWITCH TO 750MG OF LEVOFLOXACIN
• - TO START TAB AZITHROMYCIN *3/7
• - TO DO URINE RE (REQUESTED)
• - TO HOLD DEXAMETHAZONE
• - TO HOLD TB OMEPRAZOLE
PLAN
• STRICT INPUT/OUTPUT MONITORING
• -AWAITING BF FOR MPS
• -4 HOURLY RBS