GENERAL MEDICINE CASE DISCUSSIONS

17 year old female came to casualty with chief complaints of fever, headache, low back ache since yesterday.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic till yesterday, then developed which is insidious on onset, gradually progressive, not associated with chills and rigor, no diurnal variation, no sweating. 
C/o headache(diffuse type) not associated with nausea/vomiting.
C/o low back ache(diffuse type) not radiating.
No c/o cough, sob. 
PAST HISTORY :
not a k/c/o DM/HTN/TB/Epilepsy.
PERSONAL HISTORY :
appetite-normal
Sleep-adequate
Bowel and bladder-regular
No any addiction 
TREATMENT HISTORY :
No significant treatment history 
FAMILY HISTORY :
NO significant family history. 

GENERAL EXAMINATION :
Patient is conscious coherent and co-operative
Temp:Afebrile
Bp:100/60 mm hg
Pr:93/min
Spo2:100% at RA
GRBS:115 mg/dl
No pallor, icterus,cyanosis clubbing,edema,lymphadenopathy.
SYSTEMIC EXAMINATION :
cvs:S1,S2 heard
RS:NVBS heard
Abdomen:soft,non tender
CNS:NFND
PROVISIONAL DIAGNOSIS :
VIRAL PYREXIA. 

PLAN OF CARE:
1.IVF:NS,RL@75 ml/hr
2.TAB.DOLO 650mg/PO/TID
3.TAB.PANTOP 40mg/PO/OD
4.TAB.ZOFER 4MG/PO/SOS
5.INJ.OPTINEURON 1 amp in 500ml/NS/IV/OD
6.BP/PR/TEMP. charting 4th hrly


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