16year old male came with fever

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This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.


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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