19 year old with fever and headache

19 year old male came to OPD with chief complaintsvof fever and headache and generalised weakness since yesterday.

HOPI : Patient was apparently asymptomatic till yesterday then he had fever with high grade sudden in onset intermittent associated with chills.
Also complains of headache in the frontal region since yesterday and generalised weakness.
No H/o nausea, vomithing,cough and soreyhroat.
No H/o burning micturition,hematuria,Malena,pain abdomen.
No H/o chest pain , palpitations and syncope attack.
No history of photophobia, photophobia, watering of eyes


Past History:
No H/o DM ,HTN ,Thyroid ,Asthma ,CAD, Epilepsy.

Treatment History:
He is not on any treatment.

Personal History:
Diet ‐ mixed.
Appetite ‐ Normal 
Sleep ‐ adequate.
Bowel and Bladder movements ‐ regular.
Micturition -normal.
Addictions: occasionally consumes toddy.

Family History: Not significant.

General Examination: the patient is conscious, coherent, cooperative, moderately built and nourished.
He is moderately built and nourished 

PALLOR -absent 
ICTERUS -absent 
CYANOSIS -absent 
CLUBBING -absent 
EDEMA -absent 
LYMPHADENOPATHY -absent

VITALS : 
Temperature ‐103 F
Pulse rate ‐ 92 bpm
BP ‐ 110/80 mmHg
RR 18 cpm
SpO2 :98%.

Systemic Examination:
RS: BAE+, clear No wheeze ,dyspnoea.
Trachea central.
Normal vesicular breath sounds are heard.
CVS: S1 S2 + , NO added sounds or murmers.
P/A: soft and non tender
No organomegaly.
CNS : No focal Neurolical deficit.


INVESTIGATIONS 

Malarial parasite -ve 
RBS -99
Blood urea- 28
Sr creatinine-1.0


Diagnosis:
Viral pyrexia

TREATMENT 

1)Inj Neomal 1gm/IV/SOS

2)IVF NS and RL @75ml/hr

3)Tab dolo 650mg Po/QID

4)Look for postural drop of BP and bleeding manifestation 

5)Temp/BP/PR chatting 4th hourly

6)Inform SOS




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