16M viral pyrexia

 A 16 year old male came to OPD with chief complaints of  


• Fever since 7 days

• Loose stools and vomiting since 6days



HISTORY OF PRESENT ILLNESS 

Patient was apparently asyptomatic 7 days back then he developed fever which was high grade, continuous not associated with chills and rigors,got relieved 2 days back. 

He also complains  of loose stools since 6 days , 4- 5 times a day which was watery in consistency non foul smelling ,no blood is seen 

He also complains of vomitings since 6 days with 2 episodes which was  watery in consistency  non bilious non foul smelling  non blood stained 

On 22/8/22  he had 3 episodes of vomitings 

On 23/8/22 he had one episode of vomiting 

No c/o hematuria , petechiae, melena 

No H/O cold,cough,burning Micturition,SOB,chest pain,orthopnea,PND



PAST HISTORY 

Orthostatic hypotension 

N/K/C/O HTN,DM,TB,ASTHMA, CAD, EPILEPSY 


PERSONAL HISTORY 

Diet- mixed

Appetite- normal

Bowel and bladder -regular

Sleep - adequate 

Addictions - none



DAILY ROUTINE 

He  is a student.

Wakes up at 6Am 

Breakfast  at 8am

Goes to college

Lunch at 12:30pm

Goes to college 

Snacks at 5pm 

Study hour

Dinner at 8pm

Sleeps by 10pm 


FAMILY HISTORY 

Not relevant 


GENERAL PHYSICAL EXAMINATION 


Patient is conscious coherent cooperative

Well oriented to time place person

Moderately built and nourished 


Pallor absent

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema- absent



Vitals 

Temperature : 97.4 

BP 110/80 mmHg 

PR  82 bpm 

RR 16cpm 

GRBS 100mg/dl



SYSTEMIC EXAMINATION 

CVS- S1 S2 heard, no murmurs

CNS- NFD

RS- BAE ,NVBS

PA- Soft and non tender 


INVESTIGATIONS 










PROVISIONAL DIAGNOSIS 

Viral pyrexia with thrombocytopenia 



TREATMENT 

Ivf 2 NS and 2 RL @ 150ml/hr 

Inj zofer 4mg iv/ SOS

TAB Dolo 650 mg po BD 

TAB PAN 40mg po/OD









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