15/M with viral pyrexia with Thrombocytopenia
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Blood urea
CUE
BLOOD FOR MALARIA
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 15 year old male student, came to the casuality with
CHEIF COMPLAINTS :
- Fever since 4 days
- Giddiness since 4 days
- vomitings : 3 episodes since yesterday
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 4 days back ,then he developed fever ,which is high grade associated with chills , generalised body pains and headache for which he went to local RMP and received treatment (? inj ceftriaxone) but the fever didnt subside and so he was referred to kims
- h/o giddiness since 4 days was present
- h/o Voimiting since yesterday - 3 episodes, non bilious,non projectile containing food particles, non blood stained and non foul smelling
- No h/o pain abdomen
- No h/o loose stools
- No h/o cold, cough and SOB
- No h/o malena
- No h/o burning micturition
HISTORY OF PAST ILLNESS:
Not a known case of DM,HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders.
No history of surgeries and blood transfusions in the past.
PERSONAL HISTORY
Mixed diet
Sleep adequate
Appetite - decreased
Bowel and bladder movements regular
No Addictions
FAMILY HISTORY
No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.
GENERAL EXAMINATION
Patient is conscious, coherent, co-operative.
Moderately built and moderately nourished
No pallor, cyanosis, clubbing,icterus koilonychia, lymphadenopathy and edema.
VITALS
Temperature- 101 F
Pulse rate- 96 bpm
Respiratory Rate- 18 cpm
BP-110/80 mmHg
SPO2 at room air- 98%
GRBS 128 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscutation:
S1, S2 heard , No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is soft and non tender.
No organomegaly.
Bowel sounds heard.
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
INVESTIGATIONS :
On 11/08/2021
CXR
ECG
RBS
118 mg/dl
Blood urea
12 mg/dl
Serum creatinine
0.8 mg/dl
Serum electrolytes
Na - 127 meq/l
K+ - 2.6 meq/l
Cl - 102 meq/l
Dengue NS1 Antigen - negative
Hemogram
Blood grouping and RH typing
CUE
Negative
USG ABDOMEN
PROVISIONAL DIAGNOSIS
? VIRAL PYREXIA WITH THROMBOCYTOPENIA
TREATMENT
Day 1
1. IVF 2 NS, @ 75 ml/hr
2. Inj . ZOFER 4mg /iv/sos
3. Tab PCM 500 mg PO/TID
4. Inj NEOMOL 100 ml /iv/sos if temp >101 F
5. Temperature charting 4th hourly
6. W/F Bleeding manifestation
7. Tab pan 20 mg PO/BD
Day 2
SUBJECTIVE :
C/o black coloured stools
OBJECTIVE :
Temperature - 98.6 F
BP - 100/60 mm hg (supine)
- 120/100 mm hg (standing)
PR - 72 bpm
RR - 17 cpm
GRBS - 106 mg/dl
Treatment
1. IVF - 1 DNS with 1 amp optineuron @75 ml/hr, 1 NS & 1 RL @ 75 ml/hr
2. Tab pcm 500 mg /sos
3. Tab pan 20 mg /po/od
4. W/F bleeding manifestation
5. Bp & Temp charting 4th hourly
Day 3
Treatment
1. Plenty of oral fluids
2. IVF 1 NS, 1 RL , 1 DNS @ 50 ml/hr
3. Tab pcm 500 mg po/sos
4. W/F bleeding manifestation
5. Check postural hypotension
6. PR/BP Charting 4th hourly
Day 4
Treatment
1. Plenty of oral fluids
2. IVF 1 NS, 1 RL , 1 DNS @ 50 ml/hr
3. Tab pcm 500 mg po/sos
4. W/F bleeding manifestation
5. Check postural hypotension
6. PR/BP Charting 4th hourly
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