By Dr Saba Tariq

History
5o Years old female presented to emergency department of Sheikh Zaid Hospital Lahore with complaints of: Fever 3 Days Nausea .... 3 Days Vomiting. 1 Day Fever was associated with chills since 3 days, Vomiting since 1day.

History of Presenting Complaints

FEVER
Onset Sudden. High grade. Intermittent. Associated with rigors and chills. Fever occurred approximately every 48 h.


VOMITING
Onset-sudden Intermittent Associated with oral intake Reduced oral intake and easy fatigability.

Systemic history.
Anorexia Insomnia Mild headache. Past history not significant Drug history not significant Non smoker non addict.


Family History:
No family history of any infectious disease , dengue.

Personal History:
Married. 3 children.

On Examination
Dull looking Female

Vitals:
HR... .. 90/min RR. 22/min B.P. 140/85 mmHg Temp 39.4 C

Systemic Examination
Mild dehydration

Abdomen
Soft, Non tender, No mass palpable, Gut sounds audible.


CVS :
1st & 2nd heart sounds audible with no added sounds.

Chest :
Normal vesicular breathing.

CNS:
Unremarkable.

PROVISIONAL DIAGNOSIS

Dengue vs Malaria

INITIAL TREATMENT
I/V Fluids Inj. Ondansetran 4mg ...1-0-1 Inj. Ranitidine 50mg ..1-0-1 Tab Paracetamol.SOS

Investigations
Hb = 9.8 TLC = 3.4 N = 53 L = 35 PLT = 182 CR = 0.8 ESR = 50 SGPT = 17

Date Haemoglobin (12 14gm %)

04/10/11 9.8 gm %

05/10/11

06/10/11 10 gm %

07/10/11 10 gm %

9.9 gm %

Packed cell volume (PCV) (35-45%)

20.3%

23.2%

31%

Diagnostic Tests
Malaria parasite (Kit) +ve for P.falciparum (Gametocyte ring forms & Schizonts seen)

DIAGNOSIS
Malaria with leucopenia

TREATMENT

Name, Strength, Route, Dose Inj. Ondansetran 4mg 1-0-1 Inj. Ranitidine 50mg 1-0-1
Inj. Artesunate 120mg 1-0-1 Tab. Primaquine 15mg 1-0-0 Tab. Ranitidine 150mg 1-0-1

Date started

Date stopped

Remarks

04.10.11

05.10.11

Antiemetic

04.10.11

05.10.11

Antihistamine

05.10.11

07.10.11

Antimalarial

07.10.11

Continued

Antimalarial

05.10.11

Continued

Antihistamine

Therapeutic Monitoring
Symptomatic Improvement

Toxicity Monitoring
Primaquine nausea, vomiting, haemolytic anaemia(G6PD Deficient), Thrombocytopaenia, leucopaenia

Planning
Discharge Medication
Tab Primaquine 15mg 1-0-0 10 days Tab Vitamin c (chew) 500mg 1-0-0 10 days Tab Paracetamol SOS Follow up after 15 days

Patient Counseling
-Disease -Medication -Life style

QUESTIONS
Which infection does this patient have? Which parasite is infecting him? Describe the typical appearance of this parasite in thick and thin Giemsa-stained smears. Describe the clinical illness caused by this parasite. Which serious complication may occur with this infection? How would this patient be treated?

Any Questions

Thank you THANK YOU