A 29 YEAR OLD MALE VIRAL PYREXIA WITH THROMBOCYTOPENIA (NS1 POSITIVE) WITH SEROSITIS WITH VIRAL HEPATITIS
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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.
A29 year old male came to casualty, working as lecturer with C/O
On 27/9/21
Fever chart
Fever since 4 days
Giddiness since 4 days
Vomitings of 10 episodes for 1 day 3 days back
Fever: low grade, intermittent associated with chills and rigor, giddiness, sweating,nausea, vomitings
Vomitings: non bilious,non projectile,food/water as content ass with pain abdomen
Pain abdomen: thrombing type,localised to right hypochondrium and epigastric region ass with nausea and vomitings
No h/o bleeding manifestations like Malena, hematuria, petechiae
Past history:
no h/o HTN, DM,TB, Epilepsy,asthma
Personal History:
Diet:mixed
Appetite: normal
Sleep: adequate
Regular bowel and bladder movements
No addictions
Family history: Not significant
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished
No pallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy
VITALS :
Temp: afebrile
PR: 91 bpm
BP: 110/70 mm hg
Spo2 - 99% at RA
RR-18 cpm
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Bilateral vesicular breath sounds+
No crepts
PER ABDOMEN:
Abdomen is soft and mild tenderness + in right hypogastrial and epigastric region
Bowel sounds heard.
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
PROVISIONAL DIAGNOSIS:
VIRAL PYREXIA WITH THROMBOCYTOPENIA (NS1 POSITIVE) WITH SEROSITIS WITH VIRAL HEPATITIS
CLINICAL IMAGES
INVESTIGATIONS
Treatment
25/9/21
1. IVF 1 NS ,1 RL @ 100 ML/HR
2. INJ.PANTOP 40 MG IV/BD
3. INJ.ZOFER 4 MG PO/SOS
4. TAB.PCM 650 MG PO/SOS
5. TAB.ULTRACET PO/QID
6. SYP.MUCAINE GEL PO/TID
7. CHECK FOR POSTURAL HYPOTENSION
8. MONITOR VITALS 4th hrly
9. I/O AND TEMP -CHARTING
26/9/21
1. IVF 1 NS ,1 RL @ 100 ML/HR
2. INJ.PANTOP 40 MG IV/BD
3. INJ.ZOFER 4 MG PO/SOS
4. TAB.PCM 650 MG PO/SOS
5. TAB.ULTRACET PO/QID
6. SYP.MUCAINE GEL PO/TID
7. CHECK FOR POSTURAL HYPOTENSION
8. MONITOR VITALS 4th hrly
9. I/O AND TEMP -CHARTING
On 27/9/21
1. IVF 1 NS ,1 RL @ 100 ML/HR
2. INJ.PANTOP 40 MG IV/BD
3. INJ.ZOFER 4 MG PO/SOS
4. TAB.PCM 650 MG PO/SOS
5. TAB.ULTRACET PO/QID
6. SYP.MUCAINE GEL PO/TID
7. CHECK FOR POSTURAL HYPOTENSION
8. MONITOR VITALS 4th hrly
9. I/O AND TEMP -CHARTING
On 28/9/21
SOAP NOTES
DAY 4
SUBJECTIVE -
No fever spikes
OBJECTIVE -
BP -130/90 mm hg(supine)
130/90 mm hg( standing :1 min,3 min)
PR - 74 bpm
Temp - 98.5
ASSESSMENT -
VIRAL PYREXIA WITH THROMBOCYTOPENIA WITH SEROSITIS WITH VIRAL HEPATITIS
PLAN OF CARE-
1. IVF 1 NS ,1 RL @ 100 ML/HR
2. INJ.PANTOP 40 MG IV/BD
3. INJ.ZOFER 4 MG PO/SOS
4. TAB.PCM 650 MG PO/SOS
5. TAB.ULTRACET PO/QID
6. SYP.MUCAINE GEL PO/TID
7. CHECK FOR POSTURAL HYPOTENSION
8. MONITOR VITALS 4th hrly
9. I/O AND TEMP -CHARTING
On 29/9/21
SOAP NOTES
A 29 yr old male
SUBJECTIVE -
No fever spikes
OBJECTIVE -
BP -130/80 mm hg(supine)
130/80 mm hg( standing :1 min,3 min)
PR - 96 bpm
ASSESSMENT -
VIRAL PYREXIA WITH THROMBOCYTOPENIA WITH SEROSITIS WITH VIRAL HEPATITIS
PLAN OF CARE-
1. IVF 1 NS ,1 RL @ 100 ML/HR
2. INJ.PANTOP 40 MG IV/BD
3. INJ.ZOFER 4 MG PO/SOS
4. TAB.PCM 650 MG PO/SOS
5. TAB.ULTRACET PO/QID
6. SYP.MUCAINE GEL PO/TID
7. CHECK FOR POSTURAL HYPOTENSION
8. MONITOR VITALS 4th hrly
9. I/O AND TEMP -CHARTING
