A 15YR BOY WITH COMPLAINTS OF FEVER

A 15YR BOY WITH COMPLAINTS OF FEVER

 A 15year old male patient resident of Narketpalli came to the opd with the chief complaints of 

-fever since 4 days

History of presenting Illness-

Patient was apparently asymptomatic since 4 days back when he developed fever  which was sudden in onset,intermittent,low grade, associated with chills and was relieved on  medication.

-No H/O vomitings 

-No H/O cold,cough,headache,sob

-No H/O rash,pain abdomen ,loose stools ,constipation

- No H/O burning micturition 

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-97.6 C/F

BP-100/70mm of hg

PR-80 BPM

RR-18 CPM

SPO2- 98% at Room air

GRBS- 125 mg/dl

SYSTEMIC EXAMINATION-

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

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

CNS EXAMINATION-

Gait -normal

Sensations - present

Cranial nerves- intact

Reflexes- preserved

Investigations

Heamogram on 2/08/2021

                                 LFT and RFT on 2/08/2021

                                    Heamogram on 3/08/2021

Tested negative for rapid IGM dengue .

                                                 Chest x-ray pa view 

   ECG on 2/08/2021

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