This study was conducted to evaluate the modes of clinical presentations of falciparum malaria. Medical Unit 5, Civil Hospital Karachi and Ankle Sria Hospital Karachi from August 2003 to December 2005. A total of 348 patients admitted with fever were screened with peripheral blood smear for malarial parasite. One hundred and twenty two patients were smear positive. One hundred and eight were positive for plasmodium falciparum, which were included in this study. Eleven patients were positive for plasmodium vivax and three patients had co-infection with plasmodium falciparum and P vivax which were excluded. Critically ill patients were given injectible Quinine sulphate, rest of them were given either Halofantrine orArtemether orally. Out of 108 P falciparum smear positive patients, males were 74 (68.51%) and females were 34 (31.48 %). Fever was present in all patients. Jaundice was observed in 39 (36.11 %), vomiting in 32 (29.62 %), abdominal pain in 23 (21.29 %), altered state of consciousness in 26 (24.07 %), diarrhea in 9 (8.33 %), cough in 8 (7.40 %) and seizures in 2 (1.85 %) patients. Out of 108 patients 22 (20.37%) patients presented with cerebral malaria, 8 (7.40) with picture of respiratory tract infection, 9 (8.33%) patients presented with acute gastroenteritis, 9 (8.33%) with acute abdomen simulating the picture of acute pancreatitis but serum amylase and ultrasound abdomen excluded the diagnosis of acute pancreatitis. Six (5.55%) presented with the picture of acute hepatitis and 4 (3.70%) presented with fulminant hepatic failure with raised serum ammonia levels and hepatocellular jaundice with negative viral markers for hepatitis B, C and E. Three (2.77%) patients presented with a picture of acute renal failure. Apart from these, many patients were seen with various presentations of acute abdomen, clinical picture of lower respiratory tract infection, acute hepatitis with Fulminant hepatic failure being notorious. Falciparum malaria should be considered as a possibility in all febrile patients even with various presentations for malaria.