16/M came with c/o FEVER
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent
CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever
Under the guidance of
Dr. Vinay PGY3
Dr.Pavani PGY1
This is a case of 16 year old student who presented to the op with the chief complaints of
1.Fever since 7 days which is of high grade continuous not associated with chills and rigors, relieved 2 days back
It is not associated with cold cough burning micturition sob chest pain orthopnea PND
2.loose stools since 6 days 4-5 times a day
Watery in consistency,non foul smelling,not associated with blood
3. Vomitings 6days back of 2 episodes
Non bilious, non foul smelling, particles non blood stained ,watery
No complaints of hematuria, petechiae on soft palate, melena
Yesterday 3 episodes
Today as of 8 am 1 episode
ORTHOSTATIC HYPOTENSION present
PAST HISTORY
No history of CAD/CVA/Epilepsy/Asthma/TB
PERSONAL HISTORY
Diet- non veg
APETITE - normal
Bowel and bladder movements - regular
Sleep - adequate
Addictions - none
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
The patient is coherent conscious cooperative and well oriented to time place and person
He is moderately built and nourished
Pallor -absent
Icterus -absent
Cyanosis- absent
Edema -absent
Lymphadenopathy - absent
VITALS
TEMP 97.4
BP110/80
PR82
RR bae+
GRBS 100
SYSTEMIC EXAMINATION
CVS- S1 S2 heard
Cns- higher motor functions intact
Pa- soft and non tender
Rs- normal vesicular breath sounds heard
Diagnosis
Viral pyrexia with thrombocytopenia
Investigations
23/8/2022
Hemogram 1@ 8.52 am
Hemogram-2
Treatment
Ivf 2 NS and 2 RL @150ml/hr
Inj zoffer 4mg iv/sos
BP/PR/ RR/spo2 monitoring
Comments
Post a Comment