13 year old female patient with pyrexia

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Case presentation : 

A 13 year old female patient studying 7th class resident of eeduluru came to opd with 

Chief complaints:

- Fever since 1 week 

- generalised body aches and weakness since 1 week 

- cough since 1 week 

- cold since 1 week 

History of presenting illness : 

Patient was apparently asymptomatic 1 week ago then she developed fever which is insidious on onset , no progression , High grade fever , associated with chills and rigors , no aggregating factors , relived temporarily on medication , increased during night 

Later she developed cough which is dry and not associated with chest pain , non blood tinged , relived on medication , no aggrevating factors. Then she developed cold 1 week ago insidious in onset , aggregated during fever episode , relived on medication 

Generalised body aches and weakness during fever episode 

No h/o vomitings , headache , burning micturition , nausea 

No h/o odynophagea, dysphagia, diarrhoea 

Past history : 

Not a known case of hypertension, diabetes, epilepsy , tuberculosis 

Menarche - not attained 

Personal history : 

Mixed diet 

Regular bowel and bladder movements 

Inadequate sleep due to increase in fever in the nights 

No addictions 

No allergies 

Family history : 

No significant family history 

General examination : 

Patient is conscious , coherent , cooperative 

Moderately built , moderately nourished 

No signs of pallor , icterus , cyanosis , clubbing , Kolinychia, lymphadenopathy 

Vitals

BP- 120/80 mmhg 

Pulse rate - 86 bpm

RR - 13 cpm 

Temperature- afebrile 

Systemic examination : 

Cardiovascular system

Inspection

Position of trachea is appears to be central 

No chest wall abnormalities 

Apical impulse is seen 

No visible pulsations , dilated engorged veins , surgical scars , sinuses

Palpation :

Confirmed inspection findings 

Position of trachea was central 

Apex beat was localised in the 5th intercostal space 2 cms medial to mid clavicles line 

No parasternal heave , thrills , tender points 

Auscultation

S1 , s2 are heard 

Apex beat heard

No added sounds 

No murmurs heard 

Respiratory system :

Bilateral air entry is present 


Normal vesicular breath sounds are heard 

Per abdomen :

Abdomen is soft , non tender 

No signs of organomegaly 

Bowel sounds are heard 

Central nervous system :

No focal deficits 

Provisional diagnosis :

Viral pyrexia , neutropenia [ under evaluation ]

Investigations :







Fever chart 




Treatment :

1)Iv fluids 50ml/hr @ n

2)tab pcm 500 mg 

3)syrup ascoril - ls 10 ml po/tid

4)inj. Cefipime 500 mg iv / tid




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