feverprojr-malaria 19/M

 malaria - 

date of admission 18/4/2024 

date of discharge 26/4/2024



CLINICAL MALARIA[RESOLVING]

RECURRENT UTI[RESOLVING]

Case History and Clinical Findings

C/O FEVER SINCE 17/4/2024 AFTERNOON

PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 17/4 AFTERNOON , THEN DEVELOPED HIGH GRADE, INTERMITTENT FEVER , RELIEVED ON MEDICATION A/W CHILLS

H/O BURNING MICTURITION SINCE 1 DAY

H/O PAIN ABDOMEN IN THE LEFT FLANK , DRAGGING IN TYPE , NON RADIATING SINCE 1 DAY

H/O NAUSEA AND LOSS OF APPETITE SINCE 2 DAYS

N/H/O VOMITING , LOOSE STOOLS

N/H/O CONSTIPATION , COUGH , COLD

N/H/O I.V DRUG ABUSE

N/H/O TRAUMA

PAST ILLNESS

H/O SIMILAR COMPLAINTS IN FEBUARY AND MARCH

N/H/O RESPIRATORY INFECTIONS , TB

N/K/C/O THYROID DISORDERS , ASTHMA , EPILEPSY

PERSONAL HISTORY

DIET : MIXED

APPETITE : DECREASED SINCE 2 DAYS


BOWEL : NORMAL AND REGULAR

BLADDER : BURNING MICTURITION

ADDICTIONS : OCCASIONAL CONSUMPTION OF ALCOHOL STOPPED 4 MONTHS AGO

NO KNOWN ALLERGIES

FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION

PT. WAS C/C/C

NO PALLOR NO PEDAL EDEMA

NO ICTERUS NO LYMPHADENOPATHY

NO CYANOSIS NO CLUBBING

TEMPERATURE : 104 F

PULSE RATE : 120 BPM

BLOOD PRESSURE : 120/70MMHG

SPO2 : 98%

GRBS : 138MG/DL

SYSTEMIC EXAMINATION

CVS : S1, S2 +

RS : BAE+

PA : SOFT , TENDERNESS + IN LEFT FLANK

CNS : NFND

REFLEXES LEFT RIGHT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR + +

KNEE +2 +2

ANKLE + +

PLANTAR F F

UROLOGY REFERRAL DONE ON 19-04-24

ADVISE: INJ.MAGNEX FORTE 1.5 GM BD FOR 1 WEEK

DENTAL REFFERRAL DONE ON 21-4-24

ADVISE: ROOT CANAL TREATMENT AND TOOTH EXTRACTION


COURSE IN THE HOSPITAL:

A 19 YEAR OLD MALE CAME WITH COMPLAINTS OF FEVER-HIGH GRADE ,ON AND OFF SINCE 1 DAY ,PAIN ABDOMEN, BURNING MICTURITION,NAUSEA . ON FURTHER EVALUATION IT WAS FOUND THAT SIMILAR COMPLAINTS WERE THERE 3 TIMES ONCE IN A MONTH.TOTAL COUNTS WERE ELEVATED ,USG ABD SHOWED B/L RENAL CALCULI . CONSIDERING IT AS UTI INJ CIPROFLOXACIN 200MG WAS STARTED AND GIVEN FOR 1 DAY ,LATER SHIFTED TO INJ MAGNEX FORTE 1.5 GM IV FOR 3 DAYS .TOTAL COUNTS WERE IN DECREASING TRENDS FROM DAY 1 TO DAY 4 ,BUT CONTINOUS FEVER SPIKES WERE PRESENT,USG ABDOMEN SHOWED HEPATOSPLENOMEGALY FROM DAY 4 INJ FALCIGO 120 MG IV 0-12-24-48 HRS DOSES WERE GIVEN FOLLOWED BY TAB LARINATE 200MG KIT WAS GIVEN FOR 3 DAYS .ON DAY 5 ,BLOOD CULTURE SHOWED NO GROWTH , URINE CULTURES ESCHERICHIA COLI >1,00,000CFU /ML WERE ISOLATED SO INJ AMIKACIN 250 MG WAS STARTED AND GIVEN FOR 5 DAYS . SIMULTANEOUSLY TAB DOXYCYCLINE 100 MG WAS GIVEN FOR 5 DAYS TO COVER ATYPICAL ORGANISMS .FROM DAY 6 TEMPERATURE SPIKES DECREASED GRADUALLY , CLINICAL IMPROVEMENT WAS NOTICED .AT THE TIME OF DISCHARGE PATIENT VITALS IMPROVED AND HE WAS KEPT ON TAB NITROFURANTOIN AND IS DISCHARGED.

Investigation

HEMOGRAM 18/4

HB: 14

TC: 20000

PCV : 39.4

RBC : 4.45

PLATELETS : 3.94L

RFT 18/4/24

BLOOD UREA -23

SERUM CREATININE 1.2 mg/dl SODIUM 137 mmol/L POTASSIUM 3.7 mmol/LCHLORIDE 102 mmol/L

PHOSPHOROUS 2.5 mg/dl

LIVER FUNCTION TEST (LFT) 18-04-2024 Total Bilurubin 0.94 mg/dl Direct Bilurubin 0.19 mg/dl SGOT(AST) 20 IU/L SGPT(ALT) 16 IU/L ALKALINE PHOSPHATASE 135 IU/LTOTAL PROTEINS 5.9 gm/dl ALBUMIN 3.5 gm/dl

HBsAg-RAPID 18-04-2024 NegativeAnti HCV Antibodies - RAPID 18-04-2024 Non Reactive


COMPLETE URINE EXAMINATION (CUE) 19-04-2024 COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil

.

PERIPHERAL SMEAR 20-04-2024 RBC : Normocytic normochromic WBC : increased counts on smear with neutrophilia PLATELET : Adequate

HEMOGRAM - 19/4/2024

HB: 12.6

TC: 23,800

N : 88 , L : 06 , E : 1 , M : 5

PCV : 36.6

RBC : 4.06

PLATELETS : 2.8L

CBP- 20/04/2024

HB: 12.1

TC: 16,900

PLATELETS : 2.4L

HEMOGRAM - 21/04/2024

HB: 11.5

TC: 8,500

N : 85 , L : 10 , E : 1 , M : 4

PCV : 34.0

RBC : 3.83

PLATELETS : 2.36L

THYROID FUNCTION TEST

T3 -1.04 ng/ml

T4 -17.17 microg/dl

TSH- 2.42 micro iu /ml

SERUM LDH 20/4/24 - 357 IU/L

MP STRIP TEST -NEGATIVE


WIDAL TEST - NEGATIVE

SMEAR FOR MALARIAL PARASITE - NEGATIVE

BLOOD CULTURE ON 20/4/24 -NO GROWTH AFTER 24HR OF AEROBIC INCUBATION

BLOOD CULTURE ON 25/4/24 -NO GROWTH AFTER 1 WEEK OF AEROBIC INCUBATION

URINE CULTURE ON 20,/4/24-ESCHERICHIA COLI>1,00,000 CFU/ML WERE ISOLATED

USG ABDOMEN DONE ON 18/04/2024

IMPRESSION : B/L RENAL CALICULI

REVIEW USG ON 20/4/24 HEPATOSPLENOMEGALY,B/L RENAL CALCULI

REVIEW USG ON 25/4/24

IMPRESSION - HEPATOSPLENOMEGALY

HAEMOGRAM DONE ON 24-4-24

HB: 12.6

TC: 9,300

N : 70 , L : 20, E : 2 , M : 08

PCV : 37.3

RBC : 4.22

PLATELETS : 2.07L

HAEMOGRAM DONE ON 25-4-24

HB: 12.1

TC: 10900

N : 70 , L : 18

PCV : 34.1

RBC : 3.95

PLATELETS : 2.98L

HEMOGRAM - 26/4/2024

HB: 13

TC: 11,800

N : 78 , L : 12, E : 2 , M : 8


PCV : 38.2

RBC : 4.35

PLATELETS : 4.02L

Treatment Given(Enter only Generic Name)

IV FLUIDS NF/RS @ 75 ML / HR

INJ.PCM 300 MG 3 AMP. IN 100 ML NS IV SOS if temp >101 degress F

INJ. PAN 40 MG IV OD

INJ.OPTINEURON 1 AMP. IN 100 ML NS IV OD

INJ. ZOFER 4 MG IV SOS

INJ AMIKACIN 250 MG IV BD FOR 5 DAYS

INJ CIPROFLOXACIN 200MG IV BD FOR 1 DAY

INJ MAGNEX FORTE 1.5GM IV BD FOR 4 DAYS

INJ.FALCIGO 120 MG IV 0-12-24-48 HRS F/B

TAB LARINATE 200MG KIT FOR 3 DAYS

TAB.DOXYCYCLINE 100 MG PO BD FOR 5 DAYS

TAB.PCM 650 MG PO QID

SYP.ALKASTONE B6 10 ML IN 1 GLASS OF WATER PO TID





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