A 14 yr old male

A 14 yr old patient came to the casuality with cheif complaints of fever since 5days,

vomitings since 2days.

HOPI:

The patient was apparently asymptomatic 5days ago,then he developed fever,which was high grade associated with chills,and subsided on medication.vomitings since 2days,2pisodes which was non projectile and non bilious associated with food particles and he complaints of black coloured stools, 2episodes since 2days.Generalised weakness is also present.

PERSONAL HISTORY:

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 100/700 MMHG, 

PR: 86bpm 

Temp: 98.2°F, 

RR: 22 CPM, 

SPO2: 97% at room air

RS: BAE+,NVBS

CVS: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities.

Clinical images:

PROVISIONAL DIAGNOSIS:

Viral pyrexia

Investigations:

Treatment:

1) IVF NS,RL @75ML/HR

2) INJ.PAN 40 MG IV/OD

3) PLENTY OF ORAL FLUIDS

4) SOFT ORAL DIET

5)INJ.OPTINEURON 1AMP IN 100ML NS IV/OD

6) STRICT BP MONITORING 4TH HRLY