A 35 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 35 year old female daily labourer by occupation came with
INVESTIGATIONS
On 23/9/21
At 6 pm
On 24/9/21
on 25/9/21
C/O - fever since 3 days which is low grade, intermittent, associated with generalized weakness,not associated with chills and rigors,cold,cough,nausea,vomitings,loose stools,giddiness
-They went to RMP , received medication and got relieved from fever
On 22/9 since 3:30 am : profuse vomitings-non bilious,non projectile,food/water as content not associated with pain abdomen,loose stools, giddiness
No h/o similar complaints in the past
No h/o bleeding manifestations like hematuria,Malena, petechiae
Past history
Not a k/c/o HTN, DM TB, epilepsy,CVA,cad
H/o hysterectomy 6 yrs back
Personal History:
Diet:mixed
Appetite: decreased
Sleep: adequate
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: 80 bpm
BP: 100/90 mm hg
RR-16 cpm
Spo2 - 99% at RA
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
No crepts
Decreased breath sounds b/l IAA
PER ABDOMEN:
Soft,non tender
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 WITH NS1 POSITIVE
On 22/9/21
At 6 am
TREATMENT
On 22/9/21
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.ZOFER 4 MG /IV /SOS
4. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
5. Tab.pcm 650 mg /po/sos
6. Temp Charting 4 th HRLY
7. W/f bleeding manifestations, postural hypotension
8. I/O charting
On 23/9/21
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.ZOFER 4 MG /IV /SOS
4. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
5. Tab.pcm 650 mg /po/sos
6. SYP.CREMAFFIN PLUS 15ML po/hs
7. Temp Charting 4 th HRLY
8. W/f bleeding manifestations, postural hypotension
9. I/O charting
ON 24/9/21
SOAP NOTES
SUBJECTIVE
No fever spikes
Petechiae present
OBJECTIVE
Bp -120/90 mmHg(supine)
120/90 mmHg (standing 1min)
Pr - 64 bpm
ASSESSMENT
VIRAL PYREXIA WITH THROMBOCYTOPENIA with platelet count-10,000 on 23/9/21 6pm
PLAN OF TREATMENT
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.ZOFER 4 MG /IV /SOS
4. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
5. Tab.pcm 650 mg /po/sos
6. SYP.CREMAFFIN PLUS 15ML po/hs
7. Temp Charting 4 th HRLY
8. W/f bleeding manifestations, postural hypotension
9. I/O charting
On 25/9/21
SOAP NOTES
SUBJECTIVE
No fever spikes
Petechiae present
OBJECTIVE
Bp -120/80 mmHg(supine)
120/80 mmHg (standing 1min)
Pr - 71bpm
ASSESSMENT
VIRAL PYREXIA WITH THROMBOCYTOPENIA with platelet count-23,000 on 24/9/21
PLAN OF TREATMENT
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.ZOFER 4 MG /IV /SOS
4. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
5. Tab.pcm 650 mg /po/sos
6. SYP.CREMAFFIN PLUS 15ML po/hs
7. Temp Charting 4 th HRLY
8. W/f bleeding manifestations, postural hypotension
9. I/O charting
On 26/9/21
SOAP NOTES
SUBJECTIVE
No fever spikes
OBJECTIVE
Bp -110/70 mmHg(supine)
110/70 mmHg (standing 1min)
Pr - 74bpm
ASSESSMENT
VIRAL PYREXIA WITH THROMBOCYTOPENIA with platelet count-30,000 on 25/9/21
PLAN OF TREATMENT
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.ZOFER 4 MG /IV /SOS
4. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
5. Tab.pcm 650 mg /po/sos
6. SYP.CREMAFFIN PLUS 15ML po/hs
7. Temp Charting 4 th HRLY
8. W/f bleeding manifestations, postural hypotension
9. I/O charting
On 27/9/21
SOAP NOTES
SUBJECTIVE
No fever spikes
OBJECTIVE
Bp -110/80 mmHg(supine)
110/80 mmHg (standing 1min)
Pr - 80bpm
ASSESSMENT
VIRAL PYREXIA WITH THROMBOCYTOPENIA
PLAN OF TREATMENT
1.IVF RL,NS @100ML/HR
2.INJ.pan 40 MG/iv/od
3. INJ.NEOMAL 1gm IV/SOS (If temp>101 F)
4. Tab.pcm 650 mg /po/sos
5. SYP.CREMAFFIN PLUS 15ML po/hs
6. Temp Charting 4 th HRLY
7. W/f bleeding manifestations, postural hypotension
8. I/O charting
