A 15 year old boy with complaints of fever.


MEDICINE CASE DISCUSSION
This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

August 03, 2021
A 15YR BOY WITH COMPLAINTS OF FEVER
 A 15year old male patient resident of Narketpalli came to the opd with the chief complaints of 

-fever since 4 days

History of presenting Illness-

Patient was apparently asymptomatic since 4 days back when he developed fever which was sudden in onset,intermittent,low grade, associated with chills and was relieved on medication.

-No H/O vomitings 

-No H/O cold,cough,headache,sob

-No H/O rash,pain abdomen ,loose stools ,constipation

- No H/O burning micturition 



Past Illness - No h/o Diabetes, Hypertension, Tuberculosis, Epilepsy, Thyroid,Asthma, CAD,CVD. 

Personal History-
Mixed diet 
Normal appetite 
Adequate sleep 
Regular bladder and bowel movements 
No addictions 

Family History- No similar complains in the family.
No history of Diabetes, Hypertension,TB, Asthma, CAD,CVD.

General Examination-
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.

Moderately built and moderately nourished .

No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema 

VITALS-

TEMPERATURE-97.6 C/F
BP-100/70mm of hg
PR-80 BPM
RR-18 CPM
SPO2- 98% at Room air
GRBS- 125 mg/dl

SYSTEMIC EXAMINATION-

CVS EXAMINATION-
S1, S2 heard
No murmurs
Apical impulse at 5th intercoastal space lateral to mid clavicular line

RESPIRATORY SYSTEM EXAMINATION- 
Trachea-midline
Bilateral air entry present 
Normal vesicular breath sounds heard
No additional sounds

PER ABDOMINAL EXAMINATION-

INSPECTION-
Shape- Scaphoid 
Umbilicus- central and inverted
Movements with respiration- equal in all quadrants, rises with inspiration and falls during expiration 
No visible pulsations 
No visible scars or sinuses seen 
No engorged veins 
PALPATION-
No local rise of temperature 
No tenderness in any quadrants of abdomen
Liver and spleen- impalpable( no organomegaly)
PERCUSSION-
Tympanic note 
AUSCULTATION-
Bowel sounds present







CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes- preserved


Investigations





Heamogram on 2/08/2021




                                 LFT and RFT on 2/08/2021


                                    Heamogram on 3/08/2021

-platelets are reduced on smear and small clumps are seen 

Tested negative for rapid IGM dengue .



                                                 Chest x-ray pa view 



   ECG on 2/08/2021


PROBABLE DIAGNOSIS-
 FEVER WITH THROMBOCYTOPENIA.

TREATMENT GIVEN-
1. Continuous infusion of fluids RL and NS @ 100 ml/hr
2.Inj.Optineuron 1amp in 100 ml NS IV/ OD
3.Tab.Pan 40mg/OD
4.Tab.Dolo 500mg/BD

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