Noon conference

1/07/2554

 49 ( )
. .
Admit 27/6/54
CC: 3 .

 PI: 3 .
-
2-3

 RH : 1 .

.
Dx ; malaria <Plasmodium vivax> c dengue
fever admit 2 day lab
admit 3/6/54 . platelet 48,000-50,000
D/C platelet 169,000 Hct 35 vol% Dengue
IgG IgM weakly positive
Rx ; chloroquine <500> 2 tab oral stat
then 1 tab oral q 6 hrs * 1 day
then 1 tab oral OD * 2 day
Primaquine <30> 1 tab oral OD * 14 day
F/U . 6/6/54 chloroquine
<250> 2 tab oral weekly q Monday *10 week
12 tab

PH:
- 6
20
- no U/D ; DM,HT,
- ,
-
-
-
- no smoking
- alcohol 1-2 /
- no Hx blood transfusion , no Hx IVDU ,
no Hx unsafe sex

 FH: no DM, HT, malignancy, heart diease

Physical examination
GA: A man good conscious, well cooperative
V/S: BT38.5 c
PR 110 bpm
RR 20 tpm
BP 113/72 mmHg
BW 85 kgs
HEENT: not pale conjunctivae, anicteric sclerae
neck vein not engorged
SCLN and CLN impalpable
pharynx not injected
Heart: PMI at 5th ICS at midclavicular line
no heaving no thrill
normal S1S2, no murmur

 Lungs:

equal breath sound

no adventitious sound
Abdomen: soft,not tender,
liver and spleen impalpable
liver span 9 cms splenic dullness negative
Ext:
no pitting edema
no petechial hemorrhage
no rash no eschar
no spider narvi , no palmar erythema

 N/S:Fully conscious E4V5M6 stiffneck negative

pupil 3 mm RTLBE,full EOM
no facial palsy,no tongue deviation
motor power: gr V all
DTR:GR.2 all,
clonus:neg,
BBK : plantar flexion both

Problem list
Acute febrile illness
Hx of malaria<PV>

Investigation
CBC:
Hb 13 HCT 37.8 PLT 69000 WBC 5900
< PMN 82.6 %,L 5.9 %,M 11.4% E0.1%>
MCV 93.2 MCH 32 MCHC 34.4
PBS
Rbc : NCNC normal size of infected Rbc

no polychromasia no microspherocyte no
schistocyte ,ring form malaria <Plasmodium
falciparum> double chromatin dot , infected rate 3 %
Wbc : slightly decrease Wbc PMN predominate
platelet : decrease,no clumping

Investigation

UA
Sp.gr 1.015
Ph 6
Alb: trace
Sugar:neg
Blood ; trace
Ketone ; neg
Rbc: Wbc: -

 DTX stat 86 mg%

BUN 12
Cr 1.2
Na 135
K 3.6
Cl 96
HCO3 29

CK 105

TB 1.6
DB 0.3
ALT 22
AST 18
Chol 114
TP 6.5
Alb 4.1
Glob 2.4

management
Admit
5%DN/2 1000 cc IV drip 80 cc/ hrs
Regular diet
<TC 2400 kcal/day , TP 80 gm/day >
Artesunate <50mg>
6 tab oral OD c stat dose
Mefloquine <250mg>
28/6/54 5 tab oral pc
29/6/54 4 tab oral pc

 Malaria: PF ID new infection

PF PV
chemoprophylaxis
endemic area role