pyrexia

A 24yr old female patient came to the OPD with chief complaints of fever since  10 days and cough since two days 

HOPI

Patient was apparently asymptomatic 10 days ago then developed high grade fever with chills and rigors which was continuous type and relieved. Temporarily on IV medication. Fever is mainly during the night time. It is associated with headache, generalised weakness and abdominal pain after having food.

Then developed dry cough since two days occasionally which resolves spontaneously 

No c/o Rash retro orbital pain, cold vomiting, loose stools burning micturation, 

no bleeding manifestations 

No c/o chest pain, SOB ,Palpitations  decreased urine output orthopnea ,PND 

Past History 

H/o appendicectomy

N/K/C/O HTN, DM ,CAD, seizures TB,seizures, asthma 

Personal history

Mixed diet 

appetite-normal 

Bowel and bladder- regular 

General examination 

Patient was conscious coherent, cooperative

Not adequately built and  nourished

Sign of Pallor present.                                      No signs of cyanosis clubbing lymphadenopathy , edema

Fever Charting

25th and 26-10-23


Systemic examination 

C V S-S1 and S2 heard no murmurs.              RS- NVBS heard                                                       trachea is central 

Abdomen- No tenderness, No bruit heard 


INVESTIGATIONS

Provisional diagnosis :-                                 Viral Pyrexia with thrombocytopenia 


Treatment

25/10/23

IV fluids -NS -@100ml/hr

    Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO QID

Monitor vitals every 4th hrly


26/10/23

IV fluids -NS -@100ml/hr

    Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO QID

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