fever projr viral pyrexia 25/F 202409018

 viral pyrexia - 20240239128 

Diagnosis

VIRAL PYREXIA

Case History and Clinical Findings

C/O FEVER SINCE 2 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 6 DAYS AGO HAD FEVER FOR 2 DAYS AND RELEIVED ON MEDICATIONB

NOW C/O FEVER HIGH GRADE A/W CHILLS AND RIGOR AND INCREASES DURING NIGHT ,INSIDIOUS IN ONSET INTERMITTENT ,NO DIURNAL VARIATIONS A/W GENERALISED WEAKNESS ,GENERALISED BODY PAINS ,HEADACHE ,LOWER BACK PAIN

NO H/O HEMATURIA ,HEMATOCHEZIA ,MELENA

NO H/O LOOSE STOOLS, NAUSEA ,VOMITINGS

NO H/O BURNING MICTURATION AND DECREASED URINE OUTPUT

NO H/O COUGH AND COLD

HER BABY 8 MONTHS OLD ADMITTED IN PICU WITH FEVER AND RASH WITH DENGUE SHOCK SYNDROME

N/K/C/O HTN/DM/THYROID/CVA/CAD/TB/ASTHMA /EPILEPSY

GENERAL EXAMINATION

ON EXAMINATION

NOPALLOR ICTERUS, CYNOSIS, CLUBBING ,LYMPHADENOPATHY,EDEMA

TEMPRATURE 98.7F

PR: 72BPM

RR: 16CPM

BP: 100/70MMHG

SPO2: 100% ON RA

SYSTEMIC EXAMINATION:

CVS:S1S2 HEARD , NO MURMURS.

RS :BAE NORMAL, NVBS HEARD

CNS :NO FOCAL NEUROLOGIC DEFICIT

LEVEL OF CONSIOUSNESS: CONSCIOUS

SPEECH : NORMAL

NO NECK STIFFNESS

NO KERNIGS SIGN

CRANIAL NERVES, MOTOR NERVES, SENSORYSYSTEM NORMAL

GLASGOW SCALE: 15/15

LOCAL EXAMINATION:

ON EXAMINATION OF ABDOMEN:

INSPECTION:

ABDOMEN FLAT, UMBILICUS CENTRAL , INVERTED.

ALL QUADRANTS OF ABDOMEN ARE MOVING ACCORDINGLY WITH RESPIRATION.

ON PALPATION:

NO LOCAL RISE OF TEMPERATURE

NON TENDER

NO GUARDING/RIGIDITY

NO ORGANOMEGALY

ON PERCUSSION:

LIVER SPAN-NORMAL

ON AUSCULTATION:

BOWEL SOUNDS+

Investigation

WIDAL TEST - NEGATIVE

NS1 , IGM , IGG - NEGATIVE

SEROLOGY NEGATIVE

HEMOGRAM ON 24/2/24

HB –11.4 MG/DL

TLC –4,000

N/L/E/M/B –71/19/01/09/00

PLATELET -3.4 LAKHS/MM3

HEMOGRAM ON 25/2/24

HB –10.4 MG/DL

TLC –4,000

N/L/E/M/B –56/44/0/10/00

PLATELET -2.9 LAKHS/MM3

HEMOGRAM ON 26/2/24

HB –10.5 MG/DL

TLC –2500

N/L/E/M/B –52/36/02/10/00

PLATELET -3.4 LAKHS/MM3

HEMOGRAM ON 27/2/24

HB –11.3 MG/DL

TLC –3,000

N/L/E/M/B –50/40/04/06/00

PLATELET -3.2 LAKHS/MM3

CUE ON 24/2/24

ALBUMIN - NIL

SUGAE NIL

PUS CELLS - 2-3

EPITHELIAL CELLS - 2-3

RFT ON 24/2/24

UREA - 18

SR.CREATININE - 0.8

NA - 144

K - 3.6

CL - 105

CA - 1.10

RFT - ON 26/2/24

UREA 15

SR.CREATININE 0.8

NA 142

K - 3.8

CL 105

CA 1.13

LFT ON 26/2/24

TB 0.62

DB 0.20

AST 25

ALT 20

ALP 154

TP 68

ALBUMIN 3.7

A/G RATIO - 1.21

HEMOGRAM ON 28/2/24

USG ON 25/2/24

E/O HYPERECHOIC FOCII NOTED IN PARTIALLY DISTENDED GALL BLADDER

- GB MICROLITHS/SLUDGE

E/O 16 X 6 MM COLLECTION NOTED AT THE SUTURE SITE IN SUBCUTANEOUS PHASE

REVIEW SCAN ON 27/12/24 IN FASTING STATE:

E/O 5 MM HYPERECHOIC FOCUS NOTED IN NECK OF GALL BLADDER WALL THICKNESS NORMAL

- SLUDGE MICROLITHS

Treatment Given(Enter only Generic Name)

IV FLUIDS

INJ.CEFTRIAXONE 1G IV BD

TAB.PCM 500 MG PO QID

INJ.NEOMOL 1G IV SOS

INJ,METROGYL 500 IV TID

INJ.PANTOP 40 MG IV OD

TAB.CHYMEROL FORTE PO BD

TAB VIT C 500 MG PO BD

TAB.FERROUS ASCORBATE 100 MG PO OD

TAB.CALCIUM 2500 MG PO OD

PROTIEN RICH DIET WITH 2 EGG WHITES

Advice at Discharge

PROTEIN RICH DIET

GRD PPROTEIN POWDER 2 TABLE SPOONS IN 1 GLASS OF MILK

TAB.PAN 40 PO OD 30 MINS BBF

TAB.CHYMEROL FORTE PO OD X 3DAYS

TAB.VIT C PO OD X 5 DAYS

TAB.DOLO 650 MG PO OD X 3 DAYS

TAB.METROGYL 400 MG TID X 3 DAYS

OINT.ZYTEE L GEL FOR L/A