A 24 YEAR OLD FEMALE WITH VIRAL PYREXIA WITH THROMBOCYTOPENIA (dengue NS1 positive )
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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 24 year old female resident of guduguntlapalam came to the hospital with complaints of
Fever since 5 days
Dry cough since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently alright 5 days back then she had insidious onset of low grade fever, intermittent associated with sweating,body pains, vomitings,not associated with chills and rigors,relieves on taking medications
From 3 days patient is having dry cough not associated with any expectoration,no diurnal variation,not associated with postural change
No h/o of weight loss,loose stools,pain abdomen
PAST HISTORY :
N/k/c/o DM,HTN,EPILEPSY ,TB, ASTHMA
PERSONAL HISTORY :
Diet : mixed
Appetite : decreased
Bowel and bladder : normal
Sleep :adequate
Addictions:none
FAMILY HISTORY :
not significant
GENERAL EXAMINATION
O/E pt is c,c,c
No pallor ,icterus, cyanosis, clubbing, lymphadenopathy
VITALS :
Afebrile
Bp :110/70 mm hg
PR: 85bpm
Rr: 14 cpm
Spo2: 98% at RA
SYSTEMIC EXAMINATION
Cvs : s1 s2 heard
CNS: NAD
RS: BAE +
PA : soft , non tender , no organomegaly
PROVISIONAL DIAGNOSIS :
VIRAL PYREXIA WITH THROMBOCYTOPENIA (dengue NS1 positive )
INVESTIGATIONS
On 21/8/21
On 22/8/21
On 22/8/21 6 pm
On 23/8/21
Fever chart
Treatment:
On 21/8/21
1. IVF -NS,RL ,DNS@100ml/hr
2. TAB DOLO 650 mg /po/TID
3.INJ NEOMAL 1gm /iv/sos
4. Bp /temp/ RR/ spo2 monitoring 4th hrly
5.Temp monitoring 2nd hrly
6.Plenty of oral fluids
On 22/8/21
SOAP NOTES
SUBJECTIVE :
No fever spikes
OBJECTIVE :
Temp:97.6 F
PR:68 Bpm
RR: 18cpm
BP: 90/60 mmhg
Grbs :98 mg/dl
ASSESSMENT- VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive) with platelet count 70,000 today
Plan of treatment :
1. IVF -NS,RL ,DNS@100ml/hr
2. TAB DOLO 650 mg /po/TID
3.INJ NEOMAL 1gm /iv/sos
4. Bp /temp/ RR/ spo2 monitoring 4th hrly
5.Temp monitoring 2nd hrly
6.Plenty of oral fluids
On 23/8/21
SOAP NOTES
SUBJECTIVE :
No fever spikes
OBJECTIVE :
Temp:98.8 F
PR:64 Bpm
RR: 20cpm
BP: 90/60 mmhg
Grbs :98 mg/dl
ASSESSMENT- VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive) with platelet count 74,000 today
Plan of treatment :
1. IVF -NS,RL ,DNS@100ml/hr
2. TAB DOLO 650 mg /po/TID
3.INJ NEOMAL 1gm /iv/sos
4. Bp /temp/ RR/ spo2 monitoring 4th hrly
5.Temp monitoring 2nd hrly
6.Plenty of oral fluids
On 24/8/21
SOAP NOTES
A 24 yr old female with viral pyrexia with thrombocytopenia
SUBJECTIVE :
No fever spikes
OBJECTIVE :
Temp:97.6 F
PR:62 Bpm
RR: 20cpm
BP: 90/60 mmhg
ASSESSMENT- VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive) with platelet count 1.57 lakh today
Plan of treatment :
1. IVF -NS,RL ,DNS@100ml/hr
2. TAB DOLO 650 mg /po/TID
3.INJ NEOMAL 1gm /iv/sos
4. Bp /temp/ RR/ spo2 monitoring 4th hrly
5.Temp monitoring 2nd hrly
6.Plenty of oral fluids
COURSE IN THE HOSPITAL:
24 YR OLD FEMALE ADMITTED WITH COMPLAINTS OF FEVER SINCE 5 DAYS AND DRY COUGH SINCE 3 DAYS. SHE HAD LOW GRADE FEVER WHICH WAS INSIDIOUS IN ONSET, INTERMITTENT, NOT ASSOCIATED WITH CHILLS AND RIGORS, RELIEVES ON TAKING MEDICATION PATIENT ALSO HAD DRY COUGH SINCE 3 DAYS WHICH WAS NOT ASSOCIATED WITH ANY EXPECTORATION, NO DIURNAL VARIATION, NOT ASSOCIATED WITH ANY POSTURAL CHANGE. PATIENT WAS MANAGED CONSERVATIVELY WITH IV FLUIDS. PATIENT'S PLATELET COUNT WAS 35,000 WHICH IMPROVED TO 1.57 LAKH ON DAY THREE. WITH IMPROVEMENT OF OVERALL CONDITION AND RESOLUTION OF ABOVE MENTIONED SYMPTOMS, PATIENT IS BEING DISCHARGED WITH FOLLOWING MEDICATION AND ADVICED FOR FOLLOW UP AFTER ONE WEEK.
Advice at Discharge
1. PLENTY OF ORAL FLUIDS
2. TAB. ZINCOVIT PO/OD FOR ONE WEEK
3. TAB PAN 40 MG PO/OD FOR ONE WEEK
