A 50-year-old male was admitted with swelling of the lower limbs, fever, chills, vomiting, and diarrhea. He has a history of chronic kidney disease and malaria. On examination, he was febrile and had pallor, icterus, and tenderness in the abdomen. Laboratory tests showed decreased hemoglobin and kidney function. He was diagnosed with chronic kidney disease exacerbation and malaria and treated with IV fluids, antibiotics, antimalarials, and other medications. His condition improved and he was discharged on medications including antibiotics and supplements with counseling on diet, lifestyle and medication adherence.

2. DEFINITION :-
1) CKD :- Chronic kidney disease is progressive loss in
kidney function over a period of months or year.
2)MALARIA:- an intermittent and remittent fever
caused by a protozoan parasite which invades the red
blood cells and is transmitted by mosquitoes in many
tropic and subtropics regions.
3)ACUTE GE :- is the sudden onset of diarrhoea and/or
vomiting.

3. Patient Demographic Data:-
 Name:-XYZ I.P. NO.:- 51160
 Age:-50 years DOA :- 30/11/2017
 Sex:-Male
 Ward name:- MMW Unit D

4. SUBJECTIVE :-
Chief complaints:-
 A 50 years old male patient was admitted to the male
medicine unit D with
 C/O of swelling of B/L lower limbs since 15 days
C/O of fever with chills and rigor since 6 days
C/O of GBA since 6 days
H/O Vomiting 6 episode since 2 days
H/O diarrhoea 4 episode since 2 days

5. PAST MEDICAL HISTORY:-
K/C/O CKD since 9 months
PAST MEDICATION HISTORY:-
 Not taking medicine before 4 months

6. PERSONAL HISTORY :-
 Mixed diet.
 Appetite decreased
 Sleep normal
 B/B regular
FAMILY HISTORY :-
• Nothing significant

7. OBJECTIVE :-
PHYSICIAL EXAMINATION SYSTEMIC EXAMINATION
 GC:- Pt. with drowsiness
PULSE :-78 bpm
BP:-130/70 mmHg
PICCLE :- Pallor(+) , Icterus (+)
Temp. :- Febrile
 RS :- B/L NVBS(+) , No added sounds
 CVS :-S1 & S2 (+) , No murmur
 P/A : - Soft, diffused tenderness(+)
 CNS :- HMF (+), conscious &
drowsiness

8. ADVICE
 CH
 RBS
 RFT
 LFT
 Serum electrolytes
 PS for MP
 HIV test

9. LABORATORY INVESTIGATIONS
PARAMETER RESULT REFERENCE RANGE
30/11/2017
RBS 88mg/dl 80-140 mg/dl
HB % 8 gm% 13 – 17gm %
RBC 3.4millions/cumm 4.5-5.5 millions/cumm
TC 14000 cells/cumm 4000 – 1100 cells/cumm
Neutrophil 80% 50-70 %
ESR 45 mm in 1st hour 0-20mm in 1st hour
Urea 70 mg/dl 15-45 mg/dl
S. Creatinine 3.2 mg/dl 0.9 – 1.2 mg/dl
Total bilirubin 2.5 mg/dl 0-1mg/dl
Unconjugated bilirubin 1.7 mg/dl 0.1-0.8 mg/dl
Sodium 132 mmol/l 135-145mmol/l
Other Electrolyte count normal, HIV(-ve), PS for MP (+)

10. ASSESSMENT :-
 Final diagnosis: Based on subjective and objective evidences the
patient is diagnosed as :-

11. Treatment at Admission day :-
S.N DRUG ( Generic) DOSE FREQUENCY
1) IVF 2 pint NS @ 75 ml/ hr
2) Inj Ceftriaxone 1 gm 1-1-1
3) Tab . Paracetamol (DOLO 650) 650mg 1-1-1-1
4) Inj. Ranitidine 50 mg 1-0-1
5) Inj. Furosemide 40 mg 1-1-1
6) Tab . Ferrous fumarate 375 mg 1-0-1
7) Tab . Folic acid 5 mg 0-1-1
8) Tab. Sodium bicarbonate 250mg 1-1-1
9) Tab. Metronidazole 500mg 1-1-1
10) Tab. Artesunste 200mg 1-0-1
11) Syp. Lactulose 15 ml 1-0-1
12) Inj. Ondansetron 4mg 1-0-1

12.  To reduce current signs & symptoms of patients
 To control the Disease & Avoiding patient suffering
 Preventing further complications
 Use of proper drug therapy
 Patient’s understanding regarding drug & disease
along with life style modification.

13. DAY 2
Physical examination Chief complaints
 BP:110/70mmHg -Headache & Fever
 PR: 82 bpm -2 episode of vomiting
 RS:- No added sounds -3 episode of loose stool
 CVS:- S1 & S2 sound(+),no murmur
 P/A:- Soft, diffused tenderness(+)
Laboratory reports Advice
 RBS :- 86 mg/dl -USG abdomen
 Hb :- 8.2 gm% -CH
 RBC:- 3.6 million/cumm -LFT
 Nutrophile :- 70% -RFT
 ESR:- 44 mm in 1st hrs
 Sodium :- 134mmol/l
 Urea :- 60mg/dl
 S. Cr. :- 3mg/dl
Treatment plan:- APC as 1st day + Tab. Albendazole 500 mg at night

14. OTHER REPORTS :-
 ECG – Normal
 HIV :- Negative

15. DAY 3
Physical examination Chief complaints
 BP:120/70mmHg -No new fresh complaints
 PR: 80 bpm
 RS:- No added sounds
 CVS:- S1 & S2 sound(+),no murmur
 P/A:- Soft, non tenderness
 CNS :- Pt. Conscious & oriented
Laboratory reports
 RBS :- 84 mg/dl
 Hb :- 9 gm%
 RBC:- 3.6 million/cumm
 Nutrophile :- 70%
 ESR:- 40 mm/hrs
 Sodium :- 136mmol/l
 Urea :- 40 mg/dl
 S. Cr. :- 2.2 mg/dl
 USG Abdomen:- Mild hepatospleenomegaly & abdominal wall thin
Treatment plan:- APC as 2st day

16. DAY 4
Physical examination Chief complaints
 BP:110/70mmHg -Fever at evening
 PR: 79 bpm
 RS:- No added sounds
 CVS:- S1 & S2 sound(+),no murmur
 P/A:- Soft, non tenderness
 CNS :- conscious & oriented
Treatment plan:- APC as 3st day ADVICE
-CH
- LFT
-Urine routine

17. DAY 5
Physical examination Chief complaints
 BP:110/80mmHg -No new fresh complaints
 PR: 88 bpm -Pallor (-) & Icterus (+)
 RS:- No added sounds
 CVS:- S1 & S2 sound(+),no murmur
 P/A:- Soft, non tenderness
Laboratory reports
 Hb :- 10 gm%
 Urea :- 34 mg/dl
 S. Cr. :- 2.0 mg/dl
 Total bilirubin:- 1.4 mg/dl
 Unconjugated:- o.8mg/dl
Treatment plan:- APC as 4st day

18. DISCHARGE MEDICATIONS
 Tab. Paracetamol 500 mg sos
 Tab. Cefotaxim x 200mg/po x 1-0-1 for 5 days
 Tab. Calcium carbonate x 500 mg/po x 1-0-1
continue
 Tab. Folvite x 5 mg/po x 1-0-0 continue
 Tab. Livogen x 375 mg x 1-0-1 continue
 Tab. Ranitidine x 150 mg x 1-0-1 continue
 Tab. Larinate 200kit x 1-0-0 for 7 days
(Artesunate 200mg + Sulfadoxine 500mg + Pyrimethamine 25mg)
 Syp. Lactulose 1-1-1

19. About medications
 NS used to prevent dehydration
 Ceftrixone, a 3rd generation antibiotic used to prevent from infection
 Paracetamol used as analgesic and antipyretic
 Ranitidine used to suppress GI acid
 Furosemide used as loop diuretic to treat oedema
 Ferrous fumarate used for iron supplements
 Folvite used as folic acid supplement
 Metronidazol used as anti-protozoal to control diarrhoea
 Lactulose used as hepato-protective
 Artesunate used as anti-malarial
 Ondensetron used as anti-emetic to prevent vomiting
 Cefotaxim used to prevent from infection

20. INTERVENTIONS
DRUG-DRUG INTERACTIONS :-
1)Ferrous fumarate & Ranitidine (moderate)
:- H2 receptor antagonist may decrease the
absorption of iron salt. Monitor for reduced efficacy
of oral iron preparation in patient.
2) Metronidazole + Ondansetron (moderate)
:- Many enhance QTc prolongation effect
- No any change in ECG seen

21. MONITORING PARAMETERS
1. Ceftriaxone:- CBC, LFT, RFT
2. Paractamol :- serum paracetamol high level

22. 1. Ceftriaxone should give only upto 2 gm *max dose
in CKD patient
2. Furosemide should not prescribe at night time
3. Dose of paracetamol should maintain to avoid
hepato-toxicity
4. Prescribing calcium carbonate tablet may be useful
5. Folic acid should use only once a day or change
frequency morning and night

23. PATIENT COUNSELLING
Non –Pharmacological therapy
COUNSELLING ABOUT DISEASE
1) CKD :- Chronic kidney disease is slow progressive
kidney damage. Which can be controlled by drug
therapy , diet maintain & life style modification.
2) Malaria:- Malaria is caused by mosquito, which can
be treated by using medicine and by preventing
from mosquito biting.
3) Acute GE :- This is acute condition of gastritis.
Which can be curable by using drugs and
maintaining hygiene.

24. PATIENT COUNSELLING
Non –Pharmacological therapy
About Diet :-
I ) CKD
 Limit protein intake ranging from 0.6 to 0.75 gm/kg body weight /Day
 Avoid low potassium containing food and take low phosphorus
containing food.
 Avoid junks, spicy, preserved and processed food to avoid cholesterol &
fat.
II) Malaria
 Food containing high level of iron like Spinach, beet root
III) Acute GE
 Avoid spicy & oily food and eat nicely boiled food and fresh fruits

25. PATIENT COUNSELLING
COUNSELLING ABOUT LIFE STYLE MODIFICATION
1)MALARIYA
-Avoid mosquito bite by keeping mosquito net, applying Odom's, cleaning water
drainage and avoid water accumulation to surroundings.
- Try to avoid biting of mosquito at day time .
2) CKD
-Maintain hygiene
-Enough rest and light exercise
- Psychosocial support
ABOUT MEDICATION
- Take medicine in right dose and right time
-If dose missed, don’t take a double dose