16year old male came with fever

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CHIEF COMPLAINTS 

16 year old male patient came with chief complaints of

 •fever since 7 days

HOPI

Pt was apparently asymptomatic 7 days then he had fever which is high grade associated with chills and rigors more during night times. relieved by medications if taken every 4 hrly.

4 episodes of vomitings 4 days back with food as content non projectile non blood stained

There are 4 episodes of loose stools 3 days back after consuming papaya leaf juice and relieved by medication

NO H/ O cold, cough, headache, body weakness, burning micturition, hematuria, epigastric pain

PAST HISTORY 

N/K/C/O ASTHMA , EPILEPSY


FAMILY HISTORY

His grand mother has dm and htn since 17 years

DAILY ROUTINE

Patient is studying inter 1st year waked up.at 6: 30 does his daily routines and takes breakfast at 7:30 goes to clg at 9: 00 pm and takes lunch at 1:00 college ends at 4:00 he goes to home by 4: 30 goes to stadium and plays there and does his home works and takes dinner at 7: 30 and uses mobile for 10 to 15 mins before going to bed . and sleep by 9: 30 pm

PERSONAL HISTORY 

Diet - Mixed

Appetite- normal

Bowel and bladder movements- Regular

Sleep-adequate

Addictions- no


GENERAL EXAMINATION

Patient is conscious coherent cooperative, well oriented to time place person

moderatly built and moderately nourished 

Pallor- absent

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent

VITALS

Pt is c/c/c

Temp- 

BP- 120/80 mm hg

PR- 55 bpm

RR- 18 cpm


SYSTEMIC EXAMINATION

CVS- S1, S2 heard

RS- BAE+

CNS- intact

PA- Soft , non tender




Investigations 














 
PROVISIONAL DIAGNOSIS 

Pyrexia under evaluation with thrombocytopenia


TREATMEMT

1)IVF 1U NS, 1U RL @ 100 ml/ hr

2)INJ OPTINEURON 1 amp in 100 mo NS IV / BD

3)TAB DOLO 650 mg PO/ TID

4) TAB PANTOP 40 mg PO/OD




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