A 50 year old male with viral pyrexia (clinically diagnosed malaria??)
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Fever since 10 days
Generalized weakness since 10 days
Headache since 5 days
Abdominal pain since 4 days
Burning micturiton since 3 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 10 days ago then he developed
fever which was insidious in onset and gradually progressive and intermittent type associated with chills and rigor
sweating is present and the fever relieved upon medication
He also complaints of SOB which is of grade 3
History of black stool 10 days ago
He has abdominal pain which is of dragging type and is diffuse in nature
Compliants of headache which was diffuse and is not associated with nausea and vomiting
He had a history of vomiting two day ago which was non bilious and non projectile he had two such episodes
He also complaints of indigestion
HISTORY OF PAST ILLNESS
He is not a known case of hypertension, diabetes, TB, asthma, epilepsy, CVD, thyroid disorders
No past surgical history and no history of previous blood transfusions
PERSONAL HISTORY
Appetite decreased since 5 days
Diet-mixed
Bowel and bladder- regular
Sleep- adequate
Addictions- chronic alcoholic since 20 years and consumes 90 ml on a daily basis
Beetle nut chewer since 20 years
Allergies- no known allergies
FAMILY HISTORY
Non contributory
GENERAL PHYSICAL EXAMINATION
Patient is conscious coherent and cooperative
Examination was done in a well lit room after taking informed verbal consent
Pallor- present
Icterus - present
Cyanosis- absent
Clubbing- absent
Edema- absent
Lymphadenopathy- absent
Vitals on admission
Temperature:afebrile
BP:100/80mmhg
PR:98bpm
Spo2:99 % on RA
Systemic examination
CVS: S1,S2 heard, no murmurs
RS: BAE present , B/L fine crests are present in MA,IAA,ISA
CNS: HMF intact
Per abdomen : tenderness in right hypochondrium,
Guarding - present
Hepatomegaly ,
splenomegaly.
Bowel sounds - present
Fever charting
Investigations on 27th September:
ECG
Peripheral smear
Complete urine examination
Complete blood picture
Serum creatinine
LDH
Liver function tests
NS1 antigen detection
Vitals on 28th September
Bp: 110/80 mmHg
Pulse rate:78bpm
Investigations on 28th September
Malaria parasite detection
Hemogram
Investigations on 29th September
Liver function test
Diagnosis:
Viral pyrexia ? Clinical malaria
hypoalbuminemia 2° to albuminuria
Hyponatremia (? Volume loss)
Hemolytic anemia with indirect hyperbilirubinemia
Pancytopenia 2° to viral etiology?
Treatment
On 27th
1.tab. DOLO 650 MG PO/TID
2. IVF- NS,RL AT THE RATE OF 75 ML/ HR WITH 1 AMP OF OPTINEURON
3. Protein Powder in 2 teaspoons in one glass of milk or water PO/ TID
4Syrup Lactulose 10ml po/bd
5 INJ. FALCIGO 120 ml iv stat
Inj falcifo 120 ml iv at 12 24 48 hours after 0 dose
6. 3 EGG WHITES / DAY
BP/PR/SPO₂/ TEMP charting 4th hourly
On 28th
1. Tab. Dolo 650 mg / po/ tid
2. IVF- NS,RL at 75 ml/ hr with 1 amp optineuron
3. Inj. Falcigo 120 mg / iv at 12,24,48 hrs.
4. Protein powder 1 tbsp in 1 glass of milk/ water tid
5.Inj. Pan 40 mg / iv/ of
6. Inj. ZOFER 4 mg / iv/ bd
7. Egg whites 3 per day
BP/PR/SPO₂/ TEMP charting 4th hourly
On 29th
1. Tab. Dolo 650 mg / po/ tid
2. IVF- NS,RL at 75 ml/ hr with 1 amp optineuron
3. Inj. Falcigo 120 mg / iv at 12,24,48 hrs.
4. Protein powder 1 tbsp in 1 glass of milk/ water tid
5.Inj. Pan 40 mg / iv/ of
6. Inj. ZOFER 4 mg / iv/ bd
7. Egg whites 3 per day
BP/PR/SPO₂/ TEMP charting 4th hourly
On 30th
1. Tab. Dolo 650 mg / po/ tid
2. IVF- NS,RL at 75 ml/ hr with 1 amp optineuron
3. Inj. Falcigo 120 mg / iv at 12,24,48 hrs.
4. Protein powder 1 tbsp in 1 glass of milk/ water tid
5.Inj. Pan 40 mg / iv/ of
6. Inj. ZOFER 4 mg / iv/ bd
7. Egg whites 3 per day
BP/PR/SPO₂/ TEMP charting 4th hourly
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