It may serve the academic needs of medical & pharmacy students

2.  Name – Mr. X
 Age – 26 yrs
 Gender – Male
 Date of admission – 01/3/14
 Date of discharge – 5/3/14

3. Chief complaints
C/O fever, vomiting, back pain, fatigue, head
ache X 3days.
History of present illness
H/O back pain ,headache.
Past Medical History
N/K/C/O DM, HTN, BA,
Personal History
Non-alcoholic, Non-smoker.

4. Physical Examination
 Patient is conscious oriented
 Temp- 104 F Pulse- 90/min
 Bp- 130/90 mm/Hg RR- 20beats/min
Systemic examination
CVS- S1S2+ CNS- NFND
RS- NVBS P/A- Soft

5. Data's Observed Value Normal Value
Hb 12.6 gm/dl(↓) 14-18
RBC 4.4million/cubic
mm(↓)
4.2-5.6
ESR(1 Hour) 25mm/hr(↑) 15-20
Platelet 110cubic mm (↓) 140-450
Pot 3.1meq/l (↓) 3.5-5.5
Bili (T) 1.8 mg/dl(↑) 0.2-1.4
Bili (D) 1.5mg/dl (↑) 0.0-0.4
Bili (ID) 0.3mm/dl Total-Direct

6. OTHER TEST’S
 Dengue test – Negative
 Polymerase chain reaction – Positive
 MP QBC – Positive (P.vivax)
Diagnosis
Malaria

7. Drugs Dose R.O.A Frequency Duration
IV Fluids 2 Days
Cap.
Doxycycline
100mg P/O BD X 5 Days
Tab. Dolo 650mg P/O TDS X 5 Day
Tab. Larigo 600mg P/O OD X 5 Days
Inj. Emeset 4 mg I.V STAT X 2 Days

8. Discharge Advice:
Tab. Larigo (600mg) OD for 14 days
Tab. Dolo (650mg) STAT
Cap. Doxycycline (100mg) BD for 7 Days
Review after 14 Days

9.  Take adequate rest
 Drink plenty of clean water.
 MB QBC Test recommended after 14 days