Case 06

Name: Misganaw Tesfaye
ID: MMR/240/10
Submitted to: clinical practice dep’t

Date: Dec 25, 2019 G.C
Case 06
A 16-year-old female presented with high grade intermittent fever of 01 day

duration. She has chills and rigors. She has also 03 episodes of vomiting of
ingested matter and generalized body weakness.
Upon physical examination, T°=38.1°C and other findings were non-revealing.
Investigations:
 Blood film: Hemoparasite is seen
1. What are the possible differential diagnoses? (List your differential diagnoses
based on patient’s chief compliant)
The possible DDx are:
1) Dengue fever
2) Pneumonia
3) Influenza
4) Enteric fever
5) Pyogenic infection
6) Leptospirosis
7) Infectious mononucleosis
8) HIV seroconversion
9) Amoebic liver abscess
10) African trypanosomiasis
11) Meningitis
12) Babesiosis
2. Considering your differential diagnoses, which important histories would you
like to ask in this particular patient?
Important histories to be asked in this patient are:
 Characterize the onset of fever(acute or chronic)
 History of travel to malaria endemic regions
 Previous history of malarial infection
 History of flu like symptoms(arthralgia, myalgia,…)
 Characterize headache, if any(persistent or transient…)
 Lack of sense of wellbeing, abdominal discomfort, diaphoresis and
other associated sx
 The presence or absence of rash
 Medication history
 History of comorbid conditions
3. What other pertinent physical examination findings do you anticipate in this
particular patient? (Mention both pertinent positive and negative findings)
G/A:
 Acutely sick looking
 Somewhat exhausted
 shivering
V/S: tachypaenic, tachycardic, hypotensive, and febrile
HEENT: eye(pale conjunctiva, yellowish discoloration)
LGS: normal or unremarkable (if any, lymphadenopathy)
Respiratory system: pulmonary edema, difficulty breathing

CVS: -tachycardia, hypotensive
-circulatory collapse
Abdomen: hepatosplenomegaly
GUS: signs of renal failure, hemoglobinuria
MSK: arthralgia,
IGS: pallor, petechiae
CNS:
 altered consciousness with/( w/o) seizure

 Confusion,delirium or coma
4. What is the most likely diagnosis? (Please verify your reason)
The most likely diagnosis is malaria. Because :
 the presence of hemoparasite is diagnostic

 presence of high grade intermittent fever
 other sx(e.g. rigors and chills)
5. Discuss briefly on the pathophysiology of patient’s clinical presentation.
Malaria is caused by a single celled parasite of the genus plasmodium;
there are five species which infect humans, being plasmodium falciparum,
p.vivax, p. ovale, p.malariae, and p.knowlesi.
All these species are introduced into the human blood stream through the bite of
an infected mosquito; the life stage of malaria at this point is called a
“sporozoite”, and they pass first to the liver, where they undergo an initial stage
of replication (called “exo-erythrocytic replication”), before passing back into the
blood and invading red blood cells (called “erythrocytes”, hence this is the
“erythrocytic” part of the cycle). The malaria parasites that invade red blood cells
are known as merozoites, and within the cell they replicate again, bursting out
once they have completed a set number of divisions. It is this periodic rupturing
of the red blood cells that causes most of the symptoms associated with malaria,
as the host’s immune system responds to the waste products produced by the
malaria parasites and the debris from the destroyed red blood cells. Different
species of malaria rupture the red blood cells at different intervals, which leads to
the diagnostic cycles of fever which characterise malaria.
In addition, Plasmodium falciparum produces unique pathological effects, due to

its manipulation of the host’s physiology. When it infects red blood cells, it makes
them stick to the walls of tiny blood vessels deep within major organs, such as the
kidneys, lungs, heart and brain. This is called “sequestration”, and results in
reduced blood flow to these organs, causing the severe clinical symptoms
associated with this infection, such as cerebral malaria.
6. Discuss briefly on the general approach to a patient presented with fever.

History taking in patient of fever:
—A careful history should include exposures to animals; toxic fumes; potential

infectious agents; possible antigens; or other febrile or infected individuals in the
home or school.
Few salient histories:
 Age of the child

 Grade of fever
 Type of fever
 Associated symptoms
 Duration of fever
 Any seizure or unconsciousness
A history of the geographic areas in which the patient has lived and a travel
history, Information on unusual hobbies, dietary habits.
Examination:
 A meticulous physical examination should be repeated on a regular

basis. All the vital signs are relevant.
 The temperature may be taken orally or rectally, but the site users
should be consistent.
 Axillary temperatures are notoriously unreliable.
 Special attention should be paid to the skin, lymph nodes, eyes, nail
beds, cardiovascular system, chest, abdomen, musculoskeletal
system, and nervous system. Rectal examination is imperative. The
genitalia should be examined.
Investigation :
 The workup should include a complete blood count; a differential count

should be performed. Blood film should be done.
 —Urinalysis, with an examination of urinary sediment, is indicated. Any
abnormal fluid accumulation (pleural, peritoneal, joint).
 Blood film and blood culture
 Chest x- ray(CXR)
Management:
 Antipyretics
 Analgesics
 Fluid and oxygen resuscitation(if any)

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Name: Misganaw Tesfaye

Submitted to: clinical practice dep’t

A 16-year-old female presented with high grade intermittent fever of 01 day

Upon physical examination, T°=38.1°C and other findings were non-revealing.

HEENT: eye(pale conjunctiva, yellowish discoloration)

LGS: normal or unremarkable (if any, lymphadenopathy)

Respiratory system: pulmonary edema, difficulty breathing

GUS: signs of renal failure, hemoglobinuria

IGS: pallor, petechiae

 altered consciousness with/( w/o) seizure

 the presence of hemoparasite is diagnostic

In addition, Plasmodium falciparum produces unique pathological effects, due to

6. Discuss briefly on the general approach to a patient presented with fever.

—A careful history should include exposures to animals; toxic fumes; potential

Few salient histories:

 Age of the child

 A meticulous physical examination should be repeated on a regular

 The workup should include a complete blood count; a differential count

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