52.N.Geetha

 November 30 2022

A 14 year old male patient came to OPD with a complaint of high grade fever since 4 days 

History of present illness:

Patient was apparently asymptomatic 4 days back then he had high grade fever which did not relieved on medication.Then patient had loose stools(watery)and vomitings (bilious type ) and had developed headache .Then patient had developed bluish discolouration of fingers .

History of past illness :

Not a known case of htn/dm/asthma/leprosy/epilepsy

History of injury to index finger and surgery done to finger at 1 year of age .

Personal history :

Appetite :normal 

Mixed diet 

Bowel :regular 

Micturation :normal

Occupation : student

Family history :

No relevant family history 

 GENERAL EXAMINATION:

Patient is examined under well lit room and adequate ventilation with his consent taken .

Patient is conscious,coherent and cooperative well oriented to time ,space and person. He is moderately built and nourished.

Lymphadenopathy is present 

No pallor ,cyanosis ,icterus clubbing of fingers and oedema of feet .

VITALS:

Temperature :101F

Pulse rate :86bpm/min

Respiration:18cpm

BP:100/60

SYSTEMIC EXAMINATION:

CVS

Thrills :no

Cardiac murmurs :no

Cardiac sounds :

Respiratory 

Dyspnoea-no

Wheeze -no

Breathe sounds -vesicular 

Abdomen:

Shape of abdomen -scaphoid 

Palpable mass -no

Hernial orifices -normal 

Not palpable liver and spleen 


PROVISIONAL DIAGNOSIS:

Viral Pyrexia 

INVESTIGATIONS:

Haemogram 

Serum creatinine 

ECG







Treatment :

Inj Neomol

Inj. Pan

Tab zofer

Tab ofloxacin










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