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
Investigations :
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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