A 14 YEAR OLD FEMALE

D/O/admission:22-4-2022

CHIEF COMPLAINT:
A 14 year old female came to OPD with a complaint of Fever and vomitings since 2 days

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 days back then she developed fever Which was high grade, intermittent associated with 3 episodes of Vomitings (immediately after taking food)Which are non-bilious,non-Projectile.
She was taken to a local RMP doctor 2 days back When she had high grade fever for which she was given paracetomol.
The next day She was taken to Local hospital since the fever hadn't subsided and was given Inj•Arteether,Tab cefopodoxime and Tab•Dolo which fever had Touched the baseline
No H/O Rash,Malena,Bleeding manifestations

HISTORY OF PAST ILLNESS:
Not a K/C/O HTN,DM,TB,COPD

PERSONAL HISTORY:
Appetite: Lost
Diet : mixed
Bowel and bladder moments : regular
No allergies 
No addictions

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative

-Pallor present
-No cyanosis
-No Lymphadenopathy
-No icterus
-No clubbing
-No oedema

Vitals:
Temperature -Afebrile
Pulse rate -74bpm
Respiration rate -18bpm
Bp - 120/70 mmhg
Spo -98%
 
SYSTEMIC EXAMINATION:
◾CVS
No thrills
No cardiac murmurs
S1 & S2 sounds heard
◾ RESPIRATORY SYSTEM
No dyspnoea
No wheeze
Breath sounds-vesicular
◾CNS
HMF intact

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:
Dengue fever
 
TREATMENT:
T• DOLO 650 mg /PO/TID
Inj• OPTINEURON lamp in 100ml IV/OD
Inj•ZOFER 4 mg IV/SOS









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