Hyperpyrexia ??

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 A  12 year old female came to opd with 1.complaints of fever since yesterday

2 . complaints of nausea  and vomiting  since yesterday

3 . complaints of loose stools since yesterday

History of presenting illness:

Patient was apparently asymptotic till yesterday then she developed fever  which was insidious  in onset, gradually progressive not associated with chills and rigors  subsided on taking medication and she also complaints of vomiting which is non biliary, non projectile, food particle  as content

Not a known case of DM/HTN/asthma

Diagnosed  with NS1 antigen positive outside.

Personal history :

Diet :mixed

Bowel and bladder: regular

No known allergies

Sleep :adequate

Appetite:normal

Family history :not significant

On general examination :

Patient  is conscious, coherent and cooperative.

No pallor

No icterus

No clubbing

No koilonychia

No lymphadenopathy

No oedema

Vitals:

Temp 98.5 f

Pulse rate 92

Respiratory rate 18

Bp 110/80 mmhg

Spo2 99%

On systemic examination

Cvs:

s1 and s2 heard

No thrills  and murmurs

Respiratory system:

Bilateral  air entry present

Normal vesicular bronchial  sounds heard

Abdomen examination :

No abnormalities detected

CNS examination :

No abnormalities detected

Provisional  diagnosis

Fever  with thrombocytopenia (NS1 antigen positive)

Treatment

Day 1:

1.Iv fluids (NS, RL, DNS) @100ml/hr

2.Inj optineuron 1amp in 100 ml NS Iv od

3.Inj neomol 100 ml Iv NS(if temp >100 f)

4.Tab pantop 40 mg po/od

5.Tab zofer 4mg po sos

6.W/f any bleeding  manifestations

7.BP/pr/temp charting 4th hourly