19 YR OLD FEMALE WITH VIRAL PYREXIA

58 K. Sri Harshitha
 3rd Sem
Under the guidance of Dr. Jancy Intern

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 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.
 

CASE SCENARIO

A 19 year old female came to the OPD with chief complaints of fever since 4 days,vomitings since 2 days and loose stools since 1 day.

HISTORY OF PRESENT ILLNESS
Patient was  apparently assymptomatic 5 days back  then she developed
  • High grade fever associated with chills, which decreased with medication 
  • Vomitings since 2 days[ Non bilious and Non blood tinged]
  • Loose stools since 1 day[not associated with blood and mucus]
  • No H/o pain abdomen ,Hematuria, melena.
  • No H/o rashes over the skin
HISTORY OF PAST ILLNESS
  • No DM
  • No HTN
  • No CVA
  • No CAD
  • No TB
  • No Asthma

PERSONAL HISTORY
Apetite: Normal
Diet: Mixed
Bowel and bladder movements : Normal
No Addictions
No Significant family History 


 PHYSICAL EXAMINATION

GENERAL EXAMINATION:
On Examination 

Pt is conscious, coherent and cooperative 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema 

Temp- afebrile 
PR- 90bpm
RR- 22/min 
BP - 110/90  mm Hg
CVS- s1,s2+, no murmurs
RS- NVBS, BAE +
P/A - soft and non tender, bowel sounds +


 SYSTEMIC EXAMINATION 
 CNS
All Reflexes are absent

  PROVISIONAL DIAGNOSIS
Viral pyrexia with Thrombocytopenia

INVESTIGATIONS
   Serum Electrolytes
  • Na+ : 134
  • K+ : 3.4
  • Cl- : 101
 Urine Elecrolytes
  • Na+ : 168
  • K+ : 18.9
  • Cl- : 216
7/9/21
Rapid Dengue  Test


7/9/21
HIV RAPID TES T


7/9/21
HBsAg-Rapid Test




7/9/21
Hemogram


Previous Hemogram done outside on 7/9/21


7/9/21
ECG 



7/9/21
CHEST X-RAY  


Ultrasound 7/9/21                                                     

8/9/21                                                             
Peripheral Smear                                         

8/9/21
Reticulocyte Count

FEVER CHART 
SOAP NOTES
DAY -2
SUBJECTIVE - 
No fresh complaints of fever 

OBJECTIVE-
pt is c/c/c
Temp :98F
BP Supine-120/80
PR:84bpm
CVS:S1S2+
Respiratory:BAE+
P/A Soft,non tender,no palpable mass

Assesement : Viral pyrexia with thrombocytopenia 
platelet count on
7/8/21- 34,000 cells/cumm
9/8/21- 13,000 cells/cumm
Plan of care :
1. IVF NS/RL/DNS @ 100ml/hr
2.INJ.PAN 40mg/IV/OD
3.INJ.OPTINUERON 1amp in 100ml NS/IV/OD
4.ORAL FLUIDS(4L)
5.STRICT BP/PR/SPO2 MONITORING
6.STRICT TEMP CHARTING 4TH HOURLY

DAY -3
SUBJECTIVE - 
No fresh complaints of  fever 

OBJECTIVE-
pt is c/c/c
Temp :98F
BP Supine-120/60
PR:70bpm
CVS: S1S2+
RS :BAE+
P/A : Soft,non tender,no palpable mass

Assesement : Viral pyrexia with thrombocytopenia 
platelet count on
7/8/21- 34,000 cells/cumm
9/8/21- 22,000 cells/cumm
10/08/21- 32,000 cells/cumm

Plan of care :
1. IVF NS/RL/DNS @ 100ml/hr
2.INJ.PAN 40mg/IV/OD
3.INJ.OPTINUERON 1amp in 100ml NS/IV/OD
4.ORAL FLUIDS(4L)
5.STRICT BP/PR/SPO2 MONITORING
6.STRICT TEMP CHARTING 4TH HOURLY 
7.INJ.ZOFER 4mg/IV/SOS

TREATMENT PLAN
Rx
  1. IVF: NS,RL,DNS
  2. Inj: Pan 40mg/PO/OD
  3. Inj: Optiguron 10mg in 100ml/NS/IU/OD
  4. Oral fluids approx 4lit
  5. w/f Bleeding manifestations and postural drop
  6. Strict BP,PR,SpO2 monitering 6th hrly
  7. Tab. Sporiac DS/PO/TID
  8. Inj.Z0F6R 4mg/IV/TID





 















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