A 15yr boy with complaints of fever

 A 15year old male patient resident of Narketpalli came to the opd with the chief complaints of 

-fever since 4 days

History of presenting Illness-

Patient was apparently asymptomatic since 4 days back when he developed fever  which was sudden in onset,intermittent,low grade, associated with chills and was relieved on  medication.

-No H/O vomitings 

-No H/O cold,cough,headache,sob

-No H/O rash,pain abdomen ,loose stools ,constipation

- No H/O burning micturition 


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-97.6 C/F
BP-100/70mm of hg
PR-80 BPM
RR-18 CPM
SPO2- 98% at Room air
GRBS- 125 mg/dl

SYSTEMIC EXAMINATION-

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

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







CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes- preserved


Investigations





Heamogram on 2/08/2021




                                 LFT and RFT on 2/08/2021


                                    Heamogram on 3/08/2021

-platelets are reduced on smear and small clumps are seen 

Tested negative for rapid IGM dengue .


                                                 Chest x-ray pa view 



   ECG on 2/08/2021



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



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