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Patient Encounter 3, Part 2: Falciparum Malaria

TW presents with fever, nausea, headache, myalgias, chills, and body aches including back pain. When questioned about his travels, he indicates that he had not taken any antimalarial prophylaxis.

PMH: Healthy 27-year-old male

FH: Father died of stroke at age 87 years; mother, who is 82-year-old, has rheumatoid arthritis and lives with an unmarried daughter

SH: Systems analyst, works for local school district; occasionally drinks wine with meals

Meds: Ibuprofen 200 mg

ROS: In addition to the complaints noted above, he complains of severe nausea and fatigue

Gen: Patient is lucid but slightly agitated and febrile

VS: BP 105/70 mm Hg; P 120 bpm, RR 32 per minute, T 40.1°C (104.2°F)

Skin: Warm and dry to touch

HEENT: Slightly icteric sclerae and dry oral mucosa

ABD: Soft with diffuse tenderness with hepatomegaly and splenomegaly Rest of the systems were WNL

Labs: Sodium 131 mEq/L (131 mmol/L); hemoglobin 10.2 g/dL (102 g/L or 6.3 mmol/L); potassium 4.9 mEq/L (4.9 mmol/L); hematocrit 31% (0.31); chloride 96 mEq/L (96 mmol/L); WBC 14.8 x 103/mm3 (14.8 x 109/L); BUN 28 mg/dL (10 mmol/L); total bilirubin 1.8 mg/dL (30.8 pmol/L); Scr 1.4 mg/dL (124 pmol/L); platelets 110 x 103/mm3 (110 x 109/L); glucose 77 mg/dL (4.27 mmol/L); aspartate aminotransferase 87 units/L (1.45 pkat/L); albumin 3.2 g/dL (32 g/L); alanine aminotransferase 94 units/L (1.57 pkat/L); blood smear (Giemsa stain): P. falciparum

In view of the above information, what is your assessment of this patient?

Identify your treatment goals and monitoring parameters.

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