A 13 old male with fever since 2days

  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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

A 13 years old male came to the opd with chief complaints of Fever since 2days.

History of presenting illness:

Patient was apparently asymptomatic two days back then he developed high grade fever with chills and rigor associated with headache 2days back, relieved temporarily on taking medication and not associated with vomitings,diarrhoea,abdominal pain and burning micturation.(2days back).

Today(12/3/22) morning he developed  abdominal pain and burning micturation.

5 months back he has a h/o SOB and decreased blood pressure for which he was admitted to our hospital for 5 days. 

Past history:

No h/o diabetes,hypertension, tuberculosis, asthma,epilepsy.

Family history:

Not significant.

Personal history:

Diet-mixed

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-

Addictions-none

General examination:

Patient was conscious,coherent and cooperative to time place and person.Well built and well nourished.

Pallor-absent

Icterus-absent 

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

Vitals:

Temperature-100F

RR-20cpm

BP-110/60mmHg

PR-86bpm

Spo2-98%

GRBS-126mg%

Systemic examination:

CVS-S1S2 heard

RS-BAE+,NVBS+

P/A-soft,tenderness present in both hypochondriac regions and Epigastric region.

CNS-no FND.

Investigations:

Hemogram:

Hb-12.2

TLC-10,500

Pl-2.46L

MCV-75.8

MHC-26

PCV-36.5

LFT:

TB-0.56

DB-0.17

AST-18

ALT-10

ALP-347

TP-5.9

ALB-4.0

RFT:

Urea:12

Creatinine:0.4

Electrolytes:

Na+:139

K+:4.1

Cl-:98

RBS:119

CUE:

Albumin:nil

Sugars:nil

Pus cells:2-3

Epithelial cells:2-3

ECG: 

USG:

No sonological abnormality detected.

X-ray:

Provisional diagnosis:

Viral pyrexia.

 

Treatment:

Inj.MONOCEF 1gm iv BD

Tab.DOLO 650mg BD

IVF.NS with OPTINEURON at 75ml/hr

Inj.NEOMOL 1gm iv SOS

Inj.DICLOFENAC .