14 YR OLD PATIENT WITH PYREXIA

A 14 YR OLD MALE

A 14 yr old patient came to the casuality with cheif complaints of fever since 5days and vomitings since 2days.

History of Present illness:-

The patient was apparently asymptomatic 5days ago, then he developed fever which was high grade associated with chills and subsided on medication. Vomitings since 2 days, 2 episodes which was non projectile and non bilious associated with food particles and he complaints of black coloured stools, 2 episodes since 2days. Generalised weakness is also present.

PERSONAL HISTORY:-

Patient has mixed diet with normal appetite and adequate sleep.

He has normal bowel movements and bladder filling.

No addictions.

No significant family history or allergic history. 

GENERAL EXAMNATION:-

Patient is conscious, coherent and co operative with moderate built and moderate nourishment. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:-

BP: 100/700 mmhg, 

PR: 86bpm 

Temp: 98.2°F, 

RR: 22 CPM, 

SPO2: 97% at room air

SYSTEMIC EXAMNATION:-

RS: BAE+, NVBS

CVS: S1 ans S2 heard. No murmurs heard.

P/A: soft and non-tender. 

CNS: No focal deformities.

CLINICAL IMAGES:-

PROVISIONAL DIAGNOSIS:

Viral Pyrexia

INVESTIGATIONS:-

 

Treatment:-

1) IVF NS,RL @75ML/HR

2) INJ.PAN 40 MG IV/OD

3) PLENTY OF ORAL FLUIDS

4) SOFT ORAL DIET

5) INJ.OPTINEURON 1AMP IN 100ML NS IV/OD

6) STRICT BP MONITORING 4TH HRLY