13 year old female with fever and headache
A VISHAL
1701006001
This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box
13 yr old female came to the opd with chief complaints of fever & headache since 10 days
HOPI:-
Patient was Apparently asymptomatic 10 days back then she developed fever which was continous & high grade associated with chills & rigors .
No H/o burning micturition ,nausea , vomitings,loose stools,Malena,Hematuria,cold,cough, SOB.
PAST HISTORY:-
Not a k/c/o HTN,DM,Thyroid,epilepsy,CAD.
EXAMINATION
patient is c/c/c
No pallor, icterus, cyanosis, clubbing,
lymphadenopathy
VITALS:-
Bp:- 80/50
Pr:- 98bpm
Rr:- 16cpm
Spo2:-98%
GRBS:- 98mg/dl
PROVISIONAL DIAGNOSIS:-
PYREXIA UNDER EVALUATION
? ENTERIC FEVER
INVESTIGATIONS:-
TREATMENT:-
1) IVF 2× NS BOLUS, NS, RL@150 ML/HR.
2) INJ. NEOMOL 1 gm IV.
3) INJ. PAN 40 mg IV/OD.
4) INJ. ZOFER 4 mg IV /TID.
5) INJ. CEFTRIAZONE 1 gm IV /BD.
6) TAB. DOLO 650 mg QID.
Day 1
16/09/2022
S: no fresh complaints , only fever and headache
O: pt is conscious, coherent,cooperative.
Bp: 110/70
PR:76bpm
RR:16 cpm
Temp: 100.3f
CVS :s1 s2+
RS :BAE+
P/A: soft, nontender
CNS:NAD
A: pyrexia under evaluation
Plan of Treatment
1) Normal diet and plenty of oral fluid
2) IVF 1 NS @75 ml/hr
3) Inj. Neomol 1g/IV SOS
4) Inj. Pan 40 mg IV OD
5) Inj Zofer 4 mg IV tid
6) Inj. ceftriaxone 1gm iv BD
7) Tab. dolo 650 PO OD
8) Temp. And vital monitoring 4th hourly
Day 2
17/09/2022
S: no fresh complaints , only fever and headache
O: pt is conscious, coherent,cooperative.
Bp: 90/60
PR:91 bpm
RR:16 cpm
Temp: 102
CVS :s1 s2+
RS :BAE+
P/A: soft, nontender
CNS:NAD
A: pyrexia under evaluation
? Enteric fever
P:-Plan of Treatment
1) Normal diet and plenty of oral fluid
2) IVF 1 NS @100ml/hr
3) Inj. Neomol 1g/IV SOS
4) Inj. Pan 40 mg IV OD
5) Inj Zofer 4 mg IV tid
6) Inj. ceftriaxone 1gm iv BD
7) Tab. dolo 650 PO OD
8) Tab naproxen 250mg po/BD
9) Temp. And vital monitoring 4th hourly
