A 14 year old female with complaints of fever and vomitings

 A 14 year old female,student, resident of Nalgonda came to casualty on 1-8-2021 with chief complains of 2-3 episodes of vomitings since morning.


History of Presenting IllnessPatient was apparently asymptomatic 5 days back then she developed fever which was of high grade, intermittent,relieved on medication 1 day back
Now the patient had 2 -3 episodes of vomitings  ,which was non projectile,non bilious, which contains food particles.
No h/o cold, cough, SOB
No h/o pain abdomen, loose stools, melena
No h/o rash 
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-Afebrile
BP-100/70mm of hg
PR-96 BPM
RR-18 CPM
SPO2- 98% at Room air
GRBS- 150 mg/dl
SYSTEMIC EXAMINATION-
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
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
CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes- preserved
INVESTIGATIONS-

Hemogram on 1/8/2021
Hemogram on 3/8/2021
Dengue NS1 antigen- positive

Blood Urea- 14 mg/dl
Serum Creatinine- 0.8 mg/dl

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

Comments

Popular Posts