13 year old boy with fever
13 year old boy who is studying 6 th class came with chief complaints of Fever ( since 1 day ).
Patient was apparently alright till one day back he had high grade fever, which relieved on taking medication, not associated with any vomitings , loose stools , pain abdomen, not associated with any night sweats , cough , no h/o any ear pain / ear discharge .
5 months back patient got admitted in our hospital for c/o SOB ( treated conservatively for 5 days and discharged ) .
PAST HISTORY :
Not known case of DM2 , Hypertension , Asthma , TB , Epilepsy .
PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
No Pallor
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
VITALS AT ADMISSION :
Temp - 99 F
PR- 72 bpm
RR- 22 cpm
BP- 110/70 mmHg
SpO2- 98% RA
GRBS- 126 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD
PROV DIAGNOSIS :
Viral Pyrexia
TREATMENT :
1. Inj MONOCEF 1gm IV BD
2. Tab Dolo 650 mg PO BD
3. IVF NS with OPTINEURON @ 75 ml/hr
4. Inj Neomol 1 gm IV SOS
5. Vitals monitoring every hourly
6. Strict I/O charting.