CASE OF 23/F WITH VIRAL PYREXIA WITH THROMBOCYTOPENIA
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 23 year old woman , who was a student
Came to the opd with chief complaints of
1. Fever since 5 days
2. Generalised body pains and Giddiness since 5 days
3. Headache since 5 days
4. Pain abdomen since 3 days
5. Nausea and vomiting since 1 day
HOPI :
Patient was apparently asymptomatic 5 days back then she developed fever which is of high grade, intermittent associated with chills, sweating, generalised body pains and giddiness ( occasionally on getting up from bed,lasting for few seconds) .Fever relieved on taking medications. No diurnal variations and no associated rash, burning micturition,malena and loose stools
Headache since 5 days which is diffuse, dull aching type with no aggravating and relieving factors
Complaints of pain abdomen associated with abdominal discomfort and belching since 3 days ,increased on food intake
Nausea and vomiting since 1 day , 2 episodes ,non bilious,non projectile,non blood stained with food particles as content.
For the above complaints she went to a local hospital ,where she was tested positive for dengue (NS1 Ag + ) with low platelet count (50,000 cells/cumm) and was referred to kims nkp
PAST HISTORY :
No H/O DM, HTN, asthma, TB, CAD, epilepsy
No past surgical history
K/c/o PCOS since 5 years and was adviced to have dietary modification
Diagnosed with Small fibroid uterus 2 years back ,took unani medication for 3 months.fibroid got resolved within 3 months
Again after 1 year , fibroid had recurred for which she continued using unani medication till now
PERSONAL HISTORY:
Consumes mixed diet
Sleep decreased since 5 days
Appetite reduced since 3 days
Bowels and bladder movements regular
No addictions
FAMILY HISTORY : Not significant.
MENSTRUAL HISTORY:
AOM - 12 years
Before 5 Years
Regular menses,
28 days cycle,3-4 days flow
Uses 3-4 pads/day
Associated with pain and no clots
After 5 years
Irrgeular menses
Cycles irregular, 15 days of flow Sometimes 30 days flow
4/5 pads per day
Associated with clots and pain
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished & dehydrated
No pallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy
VITALS :
Temp: 100 F
PR: 84 bpm
BP:
Supine - 80/50 mm hg
Standing - 90/60 mm hg
RR: 22 cpm
Spo2 - 95% at RA
GRBS - 124 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 tenderness present in the epigastric region .
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:
25/08/21 :
HEMOGRAM :
Hb: 12.5 gm/dL
TLC: 4,500 cells/cu mm
Neutrophils: 31 %
Lymphocytes: 60 %
PCV - 34.7 vol %
MCV - 81.6 fl
MCHC - 36 %
MCH - 29.4 pg
RBC: 4.25 millions/cu mm
Platelets: 88,000 cells/cu mm
Blood grouping - O +ve
CUE :
Albumin: nil
Sugars: nil
PC: 2-3
EC: 2-3
RBC: nil
RFT :
Serum creatinine: 0.6 mg/dl
Urea - 13 mg/dl
Uric acid - 2.8 mg/dl
Sodium - 140 meq/l
K+ - 3.8 meq/l
Cl- 102 meq/l
RBS :119 mg/dl
RAPID DENGUE :
NS1: Negative
IgM: Negative
IgG: Negative
BLOOD FOR M.P STRIP TEST - Negative
LFT :
Total bilirubin: 0.91 mg/dl
Direct bilirubin: 0.20 mg/dl
SGOT: 80 IU/l
SGPT: 62 IU/l
ALP: 104 IU/l
Total protein: 5.4 gm/dl
Albumin: 3.1 gm/dl
A/G: 1.34
CXR - PA VIEW
ECG
USG :
Gall bladder wall edema
Mild ascites
26/08/21 :
HEMOGRAM
Hb - 12.4 gm/dl
TLC: 8,100 cells/cu mm
Neutrophils: 19 %
Lymphocytes: 73 %
PCV - 35.5 vol %
MCV - 82.4 fl
MCHC - 34.9 %
MCH - 28.8 pg
RBC: 4.31 millions/cu mm
Platelets: 53,000 cells/cu mm
Hb - 11.6 gm/dl
TLC: 8,100 cells/cu mm
Neutrophils: 20 %
Lymphocytes: 73 %
PCV - 33.4 vol %
MCV - 82.7 fl
MCHC - 34.7 %
MCH - 28.7 pg
RBC: 4.04 millions/cu mm
Platelets: 95,000 cells/cu mm
28/08/2021
Hb - 11.8 gm/dl
TLC: 7,600 cells/cu mm
Neutrophils: 32 %
Lymphocytes: 55 %
PCV - 34 vol %
MCV - 82.9 fl
MCHC - 34.7 %
MCH - 28.8 pg
RBC: 4.10 millions/cu mm
Platelets: 1.0 lakhs/cu mm
FEVER CHARTING
PROVISIONAL DIAGNOSIS :
VIRAL PYREXIA
WITH THROMBOCYTOPENIA
TREATMENT GIVEN :
1. IVF: 500 ml 1 NS, & 1 RL@100ml/hr
2. Plenty of oral fluids
3. Inj. PAN 40 mg/IV/OD
4. Tab. Dolo 650mg/TID.
5. Inj. NEOMOL 1gm/IV/SOS if temp > 101 F
6. Inj ZOFER 4mg/iv/sos
7. Watch for bleeding manifestations
8.Temperature monitoring 4th hourly & tepid sponging
9. Postural B.P monitoring
DAY 1 :
SOAP NOTES
SUBJECTIVE :
Fever
Giddiness
Pain abdomen
OBJECTIVE :
Temperature - 101 F
Bp
Supine - 80/50 mm hg
Standing - 90/60 mm hg
PR - 68 bpm
SPO2 - 98% at RA
GRBS - 124 mg/dl
Platelet - 53,000 cells/cumm
ASSESSMENT :
VIRAL PYREXIA WITH THROMBOCYTOPENIA
PLAN OF CARE :
1. IVF: 500 ml 1 NS, & 1 RL@100ml/hr
2. Inj. PAN 40 mg/IV/OD
3. Tab. Dolo 650mg/TID.
4. Inj. NEOMOL 1gm/IV/SOS if temp > 101 F
5. Inj ZOFER 4mg/iv/sos
6. Watch for bleeding manifestations
7.Temperature monitoring 4th hourly
8. Postural B.P monitoring
DAY 2 :
SOAP NOTES
SUBJECTIVE :
Fever spikes absent
Pain abdomen
Burning micturition
OBJECTIVE :
Temperature - 97.7 F
Bp :
Supine - 90/60 mm hg
Standing - 80/60 mm hg
PR - 72 bpm
RR - 16 cpm
SPO2 - 98% at RA
GRBS - 92 mg/dl
Platelet - 95,000 cells/cumm
ASSESSMENT :
VIRAL PYREXIA WITH THROMBOCYTOPENIA
PLAN OF CARE :
1. IVF: 500 ml 1 NS, & 1 RL@100ml/hr
2. Inj. PAN 40 mg/IV/BD
3. Tab. Dolo 650mg/TID.
4. Inj. NEOMOL 1gm/IV/SOS if temp > 101 F
5. Tab BUSCOPAN 10 mg PO/TID
6. Inj ZOFER 4mg/iv/sos
7. Syp CITRALKA 10 ml in half glass of water TID
8. Watch for bleeding manifestations
9.Temperature monitoring 4th hourly
10. Daily postural B.P monitoring
DAY 3 :
SOAP NOTES
SUBJECTIVE :
Fever spikes absent
Pain abdomen decreased
Burning micturition resolved
OBJECTIVE :
Temperature - Afebrile
Bp :
Supine - 100/80 mm hg
Standing - 90/70 mm hg
PR - 68 bpm
RR - 16 cpm
SPO2 - 98% at RA
GRBS - 126 mg/dl
Platelet - 1 lakh cells/cumm
ASSESSMENT :
VIRAL PYREXIA WITH THROMBOCYTOPENIA
PLAN OF CARE :
1. IVF: 500 ml 1 NS, & 1 RL@100ml/hr
2. Inj. PAN 40 mg/IV/BD
3. Tab. Dolo 650mg/sos
4. Inj. NEOMOL 1gm/IV/SOS if temp > 101 F
5. Tab BUSCOPAN 10 mg PO/TID
6. Inj ZOFER 4mg/iv/sos
7. Syp CITRALKA 10 ml in half glass of water TID
8. Watch for bleeding manifestations
9.Temperature monitoring 4th hourly
10. Daily postural B.P monitoring
DAY 4 :
SOAP NOTES
SUBJECTIVE :
Fever spikes absent
Pain abdomen resolved
Burning micturition resolved
OBJECTIVE :
Temperature - Afebrile
Bp :
Supine - 90/80 mm hg
Standing - 90/70 mm hg
PR - 68 bpm
RR - 16 cpm
SPO2 - 98% at RA
GRBS - 126 mg/dl
Platelet - 1.6 lakh cells/cumm
ASSESSMENT :
VIRAL PYREXIA WITH THROMBOCYTOPENIA
PLAN OF CARE :
1. IVF: 500 ml 1 NS, & 1 RL@100ml/hr
2. Inj. PAN 40 mg/IV/BD
3. Tab. Dolo 650mg/sos
4. Inj. NEOMOL 1gm/IV/SOS if temp > 101 F
5. Tab BUSCOPAN 10 mg PO/TID
6. Inj ZOFER 4mg/iv/sos
7. Syp CITRALKA 10 ml in half glass of water TID
8. Watch for bleeding manifestations
9.Temperature monitoring 4th hourly
10. Daily postural B.P monitoring
Comments
Post a Comment