18year old male with viral pyrexia under evaluation
A 18year old male resident of kattangur came in to casualty with chief complaints of
fever since 2days. C/o lower back pain since 2days.c/o general bodypains since 2days.
No h/o cold,cough.
No h/o pedal edema, decreased urine outfit,palpitations,chest pain.
History of present illness
Patient was apparently asymptomatic 2days back then he developed fever which is of incidious in onset, intermittent and is of high grade fever,a/w chills and relieved on medication a/w head ache.
No h/o any burning micturition,throat pain,cold,cough.
PAST HISTORY:
Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.
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 c/c/c with moderate built and moderate nourishment.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
VITALS:
BP: 80/60 MMHG,
PR: 98bpm
Temp: 98.2°F,
RR: 19 CPM,
SPO2: 99%
RS: BAE+,NVBS
CVS: S1 ans S2 heard. No murmurs.
P/A: soft and non-tender.
CNS: No focal deformities.
INVESTIGATIONS:
1) HEMOGRAM :
Hb: 13.3
TLC: 10500
N:92
L:6
PCV: 38.4
Mcv:76
MCH:26
MCHC:34.6
Rbc-5.05
Plc-2.77
2) LFT:
TB: 1.01
DB: 0.20
SGOT: 18
SGPT: 10
ALP: 296
TP: 5.9
A: 2.9
A/G: 0.99
3)CUE
Alb:nill
Sug:nill
Ec:2-3
Pc:2-3
RBC:nill
4)serum creatinine-1.0
5)serum electrolytes
Na+:139
K+:3.8
Cl-:98
PROVISIONAL DIAGNOSIS:VIRAL PYREXIA UNDER EVALUATION
Treatment Given
1)IV fluids- NS,RL @100 ml/hr
2)Inj.pan 40 mg IV od
3)Inj.optineuron 1 amp in 100 ml NS IV od
4)Tab.ultracet 1/2 tab po qid
5)Strict temperature monitoring 4th hourly
6)Strict bp,pr monitoring 4th hourly.
SOAP NOTES ON DAY 1
S- no fresh complaints.
O- bp-90/60 mm hg.
Pr-72 bpm
Rr-18
Cvs-s1, s2 heard
Resp-BAE +
P/A- soft,non tender.
A-Viral pyrexia under evaluation
P-
IV fluids- NS,RL @100 ml/hr
Inj.pan 40 mg IV od
Inj.optineuron 1 amp in 100 ml NS IV od
Tab.ultracet 1/2 tab po qid
Strict temperature monitoring 4th hourly
Strict bp,pr monitoring 4th hourly.
SOAP NOTES ON DAY2
S- no fresh complaints.
O- bp-100/50 mm hg.
Pr-68 bpm
Rr-18
Cvs-s1, s2 heard
Resp-BAE +
P/A- soft,non tender.
A-Viral pyrexia under evaluation
P-
IV fluids- NS,RL @100 ml/hr
Inj.pan 40 mg IV od
Tab.ultracet 1/2 tab po qid
Tab.pcm 650mg po sos
Strict temperature monitoring 4th hourly
Strict bp,pr monitoring 4th hourly.
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