DEMOGRAPHIC DATA
Name: Joseph Simon
Age: 8 years
Sex: Male
Tribe: Hehe
Occupation: Student
Religion: Christian
Address: Hombolo
Three days post admission in the ward
Date of history taking:9thJuly 2020
CHIEF COMPLAIN
Fever for 3 days
HISTORY OF PRESENTING ILLNESS
The patient was apparent well until 3 days when he started experiencing fever for 3 day which
was on and off with gradual onset, and persistent with no aggravated factor but was relieved
when taken paracetamol and it was associated with vomiting everything which was non
projectile contained food particles, convulsion, generalized joint pain, dizziness, generalized
headache ,mild abdominal discomfort, dry cough but not in severe, generalized body malaise and
the patient denied the history of loss of consciousness, awareness of heart beat, blurred vision,
painful micturition, frequency urination, diarrhea, chest pain, chest tightness, fast breathing.
RVIEW OTRHER SYSTEM
No any discharge per nose and ear
PAST MEDICAL HISTORY
Now its first admission
No history of any surgical procedure
No history of blood transfusion
No history of any known drug or food allergy
ANTE NATAL HISTORY
Mother booked antenatal clinic at 22 weeks of gestation and attended 4 visit
Received all immunization TT, FeFo, SP and mebendazole for deworming
She was also screened for HIV, Sexual Transmitted Infection
NATAL HISTORY
Hospital delivery
Caesarean section delivery due pregnancy induced hypertension
Term delivery
The baby cried soon after delivery
POST NATAL HOSTORY
No complaint specified by the mother,cord drop after 4days
IMMUNISATION HISTORY
The child was received all immunisation according to the age
DIATERY HISTORY
The child was excursively breastfed for six months then shifted to porridge which was prepared
by using maize, peanuts,mixed with milk,current eat ugali,rice,beans fish and others three times a
day.It is good in term of quality and quantity
DEVELOPMENTAL MILE STONES
The child started to
Sitting at 4 month
Crawling at 6 month
Standing with support at 9 month
Walking at 12 month
Speech at 9 month
Now study primary school
FAMILY AND SOCIALAL HISTORY
First born in the family
Living with both parents
No history of chronic illness such as asthma,
Both his mother and father are peasants
GENERAL EXAMINATION
The patient is conscious oriented with people time and place
Normal hair texture
No ear, nose and eye discharge
Not pale
Not jaundice
Not cyanotic
No oral thrush
No palpable lymph node enlargement
No finger clubbing
No lower limb edema
VITAL SIGN
Temperature=35.90C, normal
Respiratory rate=22breath/min, normal
Pulse rate=79beat/min, normal
Blood pressure-126/71mmHg, normal
CENTRAL NERVOUS SYSTEM EXAMINATION
The patient is conscious oriented with people place and time
No neck stiffness
All cranial nerves are intact
Normal muscle power
Normal muscle tones
Normal coordination
PER ABDOMINAL EXAMINATION
Not distended
The abdominal moves with respiration
No surgical or therapeutic mark
No visible distended veins
No palpable enlarged liver and spleen
Both kidneys are not ballotable
Tympanic on percussion
Normal bowel sound heard
CARDIOVASCULAR SYSTEM EXAMINATION
Normal contour of the pericardium
No pericardial hyperactivity
Apex beat is found at 5th intercostals space along the left mid clavicular line
Sound one and sound two heard with no any added sound
RESPIRATORY SYSTEM EXAMINATION
Symmetrical chest movement
No any chest deformities like kyphosis, scoliosis, pectus excavutum and carinutum
Trachea is central located
Normal tactile vocal fremitus
Resonant sound on percussion was heard
Vesicular sound heard on auscultation
SUMMURAY
A 8 years old boy from Hombolo who come with a complain of fever for 3 days which was
associated with was associated with vomiting everything which was non projectile contained
food particles, convulsion, generalized joint pain, dizziness, generalized headache, mild
abdominal discomfort, dry cough but not in severe, and generalize body malaise with no history
of loss consciousness, painful micturition and frequency urination. On examinationnormal
findings in all systems
DIAGNOSIS
Severe malaria due to fever, vomiting everything,convulsion, generalized joint pain, dizziness,
generalized headache, mild abdominal discomfort.
DIFFERENTIAL DIAGNOSIS
Typhoid fever due to fever, vomiting, abdominal discomfort.
Urinary tract infction
Septicemia
INVESTIGATIONS
Malaria rapid diagnostic test (mRDT) for malaria parasite
Widal test for typhoid fever
Urinalysis to rule out urinary tract infection
Full blood picture to check sign of infection
TREAMENT
Artesunate intravenous 2.4mg at 0 hour, 12hours, and 24 hours then medication switched to oral
tabs Artemether Lumefantrine 140mg where Artemether has 120mg and lumefantrine has 20mg
for 3 days
Tabs paracetamol 500mg 8 hourly for three days
PREVENTION
i. Early diagnosis and treatment
ii. Health education should be provided for community on the importance of using treated
net mosquitoes
iii. Improve environment sanitation
DISCUSSION
Malaria: An acute infective illness and important parasitic disease in man. The infection is
often accompanied by attacks of fever which may be periodic. Malaria is the most common
disease in the tropical Africa.
Causative Agents of Malaria
There are 4 different species of the malaria parasite which infect humans and these are:
o Plasmodium falciparum commonest cause of malaria in Tanzania.
o Plasmodium malariae
o Plasmodium vivax Not common in Tanzania
o Plasmodium ovale
CLASSIFICATION OF MALARIA DISEASE
Malaria classified into two categories
i. Uncomplicated malaria and
ii. Severe malaria
Transmission of Malaria
Malaria is transmitted by the female anopheles mosquito which requires human blood for the
development of its eggs. During sucking of blood from the human it inject plasmosmodium
into the blood circulatory system of the human
Symptoms and signs of Malaria
The signs and symptoms of malaria are non – specific and can mimic those of many other
infections as can be seen from the list and discussion below.
Fever and chill
General malaise
Joint pain, backache
Nausea, vomiting and diarrhoea
Headache
High temperature, rigors
Periods of Sweating and diarrhoea
Spleen enlargement
o The spleen enlarges with each attack of malaria because the spleen has to clear the
damaged red cells and produces antibodies
Jaundice, (Haemolytic )
Convulsion
Anaemia (mainly haemolytic)
Dizziness
Complications of Malaria
Coma
Renal failure
Severe anaemia
Pulmonary oedema
Heart failure
TREATMENT
Artesunate intravenous 2.4mg at 0 hour, 12hours, and 24 hours then medication switched to oral
tabs Artemether Lumefantrine 140mg where Artemether has 120mg and lumefantrine has 20mg
for 3 days
PREVENTION
i. Prevent breeding environment sanitation
ii. Individuals should use insecticide treated net daily
iii. Early diagnosis and treatment
REFERENCE
1.Kingondu, T., et al (2007). Communicable Diseases. Nairobi: AMREF.
2.Davidson, S. (2006). Principles and Practice of Medicine (20thed.). Churchill: Livingstone.
