14 year old female with vomitings and pain abdomen
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A 14 year old female,student, resident of Nalgonda came to casualty on 1-8-2021 with chief complains of 2-3 episodes of vomitings since morning.
History of Presenting Illness- Patient was apparently asymptomatic 5 days back then she developed fever which was of high grade, intermittent,relieved on medication 1 day back
Now the patient had 2 -3 episodes of vomitings ,which was non projectile,non bilious, which contains food particles.
No h/o cold, cough, SOB
No h/o pain abdomen, loose stools, melena
No h/o rash
Past Illness - No h/o Diabetes, Hypertension, Tuberculosis, Epilepsy, Thyroid,Asthma, CAD,CVD.
Personal History-
Mixed diet
Normal appetite
Adequate sleep
Regular bladder and bowel movements
No addictions
Family History- No similar complains in the family.
No history of Diabetes, Hypertension,TB, Asthma, CAD,CVD.
General Examination-
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.
Moderately built and moderately nourished .
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema
VITALS-
TEMPERATURE-Afebrile
BP-100/70mm of hg
PR-96 BPM
RR-18 CPM
SPO2- 98% at Room air
GRBS- 150 mg/dl
SYSTEMIC EXAMINATION-
PER ABDOMINAL EXAMINATION-
INSPECTION-
Shape- Scaphoid
Umbilicus- central and inverted
Movements with respiration- equal in all quadrants, rises with inspiration and falls during expiration
No visible pulsations
No visible scars or sinuses seen
No engorged veins
PALPATION-
No local rise of temperature
No tenderness in any quadrants of abdomen
Liver and spleen- impalpable( no organomegaly)
PERCUSSION-
Tympanic note
AUSCULTATION-
Bowel sounds present
CVS EXAMINATION-
S1, S2 heard
No murmurs
Apical impulse at 5th intercoastal space lateral to mid clavicular line
RESPIRATORY SYSTEM EXAMINATION-
Trachea-midline
Bilateral air entry present
Normal vesicular breath sounds heard
No additional sounds
CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes- preserved
INVESTIGATIONS-
Hemogram on 1/8/2021
Hemogram on 3/8/2021
Serum Creatinine- 0.8 mg/dl
PROBABLE DIAGNOSIS- FEVER WITH THROMBOCYTOPENIA.
TREATMENT GIVEN-
1. Continuous infusion of fluids RL and NS @ 100 ml/hr
2.Inj.Optineuron 1amp in 100 ml NS IV/ OD
3.Tab.Pan 40mg/OD
4.Tab.Dolo 500mg/BD
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