fever projr malaria 58Y/M 40363

 malaria - 202340363



PYREXIA SECONDARY TO CLINICAL MALARIA

K/C/O DM II SINCE 10 YEARS,K/C/O HTN SINCE 10 YEARS

LUMBAR RADICULOPATHY,FOLLICULITIS.

Case History and Clinical Findings

C/O FEVER SINCE 15 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED FEVER OF HIGH GRADE ASSOCIATED WITH CHILLS AND RIGOR RELIEVED WITH MEDICATION BUT RECURRING ,INTERMITTENT .GENERALIZED BODY PAINS PRESENT ,RETRO ORBITAL PAIN PRESENT ,HEADACHE PRESENT,DIFFUSE TYPE ,PHOTOPHOBIA AND PHONOPHOBIA ABSENT,BLURRING OF VISION ABSENT , WATERING OF EYES ABSENT.

VOMITING SINCE 1 DAYS,1 EPISODE ASSOCIATED WITH NAUSEA PRESENT ,NON PROJECTILE ,NON BILIOUS,CONTAIN FOOD PARTICLE AS CONTENT.

C/O COLD AND DRY COUGH SINCE TODAY

NO H/O SORE THROAT ,ABDOMINAL PAIN,LOOSE STOOLS,CONSTIPATION

PAST HISTORY :

K/C/O DM II SINCE 10 YEARS,K/C/O HTN SINCE 10 YEARS


NOT A K/C/O CAD , CVA,EPILEPSY,

GENERAL EXAMINATION:

THE PATIENT IS CONSIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME, PLACE AND PERSON, MODERATELY BUILT AND NOURISHED.

VITALS:

BP: 110/80 MMHG

PR: 100 BPM

RR: 18 CPM

TEMP: 104 F

CVS: S1, S2 HEARD, NO MURMURS

RS: BAE +, NVBS, NO ADDED SOUNDS

P/A: SOFT, NON TENDER

CNS: NFND

COURSE IN THE HOSPITAL :

57 YRS MALE WAS ADMITTED WITH ABOVE MENTIONED COMPLAINTS. NECESSARY EXAMINATIONS AND INVESTIGATIONS WERE DONE AND DIAGNOSED AS PYREXIA SECONDARY TO ? CLINICAL MALARIA .,PATIENT WAS TREATED WITH ANTIBIOTICS AND ANTI MALARIAL MEDICATION. THE SYMPTOMS SUBSIDED. PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE.

ORTHO REFERRAL WAS TAKEN IN/V/O LOWER BACK PAIN AND ADVISED FOLLOWED

DERMATOLOGY RFERRAL WAS TAKEN IN/V/O PAINFUL LESIONS IN B/L LOWER LIMBS AND ADVISED FOLLOWED

Investigation

BLOOD UREA08-09-2023 10:04:AM38 mg/dl

42-12 mg/dl

SERUM CREATININE08-09-2023 10:04:AM

1.2 mg/dl1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 08-09-2023 10:04:AM

SODIUM138 mEq/L

145-136 mEq/L

POTASSIUM3.5 mEq/L

5.1-3.5 mEq/l

CHLORIDE98 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.22 mmol/L

mmol/L

COMPLETE URINE EXAMINATION (CUE) 08-09-2023

10:04:AM COLOUR

Pale yellow

APPEARANCE

CLEAR

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

NIL

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

2-3

EPITHELIAL CELLS

2-4

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent


OTHERS

Nil

WIDAL TEST 08-09-2023 10:04:AM S.typhi 'O' Antibodies

NO AGGLUTINATION SEEN

S.typhi 'H' Antibodies

No Agglutinationseen

S.PARATYPHI 'AH' ANTIBODY

No Agglutinationseen

S.PARATYPHI 'BH' ANTIBODY

No Agglutinationseen

POST LUNCH BLOOD SUGAR09-09-2023 09:03:AM

140 mg/dl140-0 mg/dlHBsAg-RAPID09-09-2023 09:03:AM

Negative

BLOOD UREA09-09-2023 09:39:AM26 mg/dl

42-12 mg/d

l

SERUM CREATININE 09-09-2023 09:39:AM

Serum Creatinine1.0 mg/dl

1.3-0.9 mg/dl

Serum Creatinine1.0 mg/dl

1.3-0.9 mg/dl

ON 8/09/23

HEMOGRAM :

HB - 12.2 GM/DL

TLC - 12,100 CELLS/CUMM

PCV - 35.1 VOL%

PLATELET - 2.54 LAKHS/CUMM

RBC -4.06 MILLION /CU MM

ON 9/9/23

HEMOGRAM :

HB - 11.6 GM/DL

TLC - 16,000 CELLS/CUMM


PLATELET - 2.08 LAKHS/CUMM

RBC -3.84 MILLION /CU MM

ON 10/9/23

HEMOGRAM :

HB - 11.2 GM/DL

TLC - 10,500 CELLS/CUMM

PLATELET - 1.9 LAKHS/CUMM

RBC -3.7 MILLION /CU MM

ON 11/9/23

HEMOGRAM :

HB - 11.4 GM/DL

TLC - 8,500 CELLS/CUMM

PLATELET - 2.3 LAKHS/CUMM

RBC -3.82 MILLION /CU MM

X RAY L SPINE :

DEGENERATIVE CHANGES SEEN.

2D ECHO:

IMPRESSION:- TRIVIAL TR + ; NO MR/AR

NO RWMA NO AS/MS,SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION + ; NO PAH/PE

Treatment Given(Enter only Generic Name)

1.IV FLUIDS NS @ 100 ML/HR

2.INJ CEFTRIAXONE 1 GM IV/BD

3.INJ DOXYCYCLINE 100 MG IV/BD

4.INJ FALCIGO 120 MG IV

5.INJ OPTINEURON 1 AMP IN 100 ML NS

6. INJ NEOMOL 1 GM IV/SOS

7. INJ ZOFER 4 MG IV/SOS

8.TAB DOLO 650 MG PO/TID

9.TEMP CHARTING EVERY 2ND HOURLY

10.MONITOR VITALS EVERY 4 TH HOURLY

Advice at Discharge

1.TAB PCM 500 MG PO/SOS


2.TAB ULTRACET PO/BD X 5 DAYS

3.TAB VITAMIN E ACETATE AND LEVOCARNITINEN PO/OD X 15 DAYS

4.TAB MYORIL PO/BD X 5 DAYS

5.TAB PAN 40 MG PO/OD X 5 DAYS

6.T BACT OINTMENT L/A /BD FOR 2 WEEKS .





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