DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Malaria falciparum.
2. Ruled out meningitis.
3. Hypertension, blood pressure stable.
4. Thrombocytopenia, platelet level normal.
5. Increased liver function tests.
BRIEF HISTORY AND HOSPITAL COURSE: The patient is a (XX)-year-old male who was admitted to this facility after he had presented with severe fever, headache, vomiting, neck stiffness and sickness. The patient traveled to West Africa two months ago. It was diagnosed empirically as malaria, and the patient was started on medications for falciparum-resistant malaria with quinine sulfate and doxycycline. An LP was warranted at the time of admission and was planned by the ER physician; however, it could not be done in view of the platelet level being 56,000. Also, on further evaluation, the patient was found to have bilirubin of 1.8, and UA had shown rbc’s of 26 with wbc’s of 13. The patient also had some abdominal pain.
Further workup was done. White count was 4600, hemoglobin 11.6, and hematocrit 34. EKG was normal sinus rhythm. Chest x-ray was clear. Normal differential count from the differential counting. The patient was admitted with a diagnosis of fever, rule out malaria, epigastric pain, headache, hypertension, and low platelets. An LP could not be immediately done as the platelets were still low. However, peripheral smear was done with thin smear, which was negative. However, the thick smear had shown rare malarial ring forms and the percentage was less than 0.1.
The patient had an ultrasound of the abdomen, which was negative. The platelet level came up to 118,000. An LP was later done, which showed protein total of 22, glucose of 60, cell count, wbc 1 and rbc’s 6. Smear and culture so far are negative. Repeat UA was done, which showed wbc’s of 13 and rbc’s of 2. Nitrites negative. Leukocyte esterase negative. The patient was doing much better. He was discontinued off the Rocephin, which was started on admission, pending diagnosis of meningitis.
DISCHARGE INSTRUCTIONS: The patient is to be continued on quinine sulfate and doxycycline for a few more days, and follow up with the patient’s primary doctor.
