Mr. X, a 26-year-old male, was admitted to the hospital on January 1, 2014 complaining of fever, vomiting, back pain, and fatigue for 3 days. His physical examination showed a temperature of 104°F, blood pressure of 130/90 mmHg, and lab tests revealed decreased hemoglobin, red blood cells, and platelets. Tests were positive for malaria via polymerase chain reaction and blood smear, and he was diagnosed with and treated for malaria with intravenous fluids, doxycycline, dolo, and larigo tablets. He was discharged on March 5, 2014 with advice to continue larigo for 14 days, doxycycline for 7 days, and follow-up in 14 days

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