VIRAL PYREXIA WITH THROMBOCYTOPENIA
CBBLE UDHC SIMILAR CASES
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
March 12,2022
A 55 year old male farmer by occupation, resident of Nalgonda came with the chief complains of
Fever since 5 days which is of low grade, intermittent and relieved on local medication. Not associated with chills and rigors.
relieved on medication.
Headache in the frontal region
No h/o vomitings, blurring of vision giddiness,cold,cough,SOB, melena,bleeding gums,hematuria, rash.
No other complains
Went to local RMP for evaluation of fever and Ns1 was positive. brought to our hospital in view of ns1 positive
PAST HISTORY:
No h/o HTN, DM,TB Asthma, Epilepsy,CVD.
PERSONAL HISTORY:
DIET - MIXED,
APPETITE -REDUCED SINCE 5 DAYS
BOWEL MOVEMENT - REGULAR ,
BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - OCASSIONALLY TODDY HISTORY-2 BOTTLES
TREATMENT HISTORY:
NON SIGNIFICANT
O/E:
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO ICTRUS
NO PALLOR
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA
Vitals-
Temperature- 99F
PR- 64bpm
BP- 100/70mm hg(supine)
Standing-90/70 mm of hg
RR- 18 cpm
Spo2- 98%at room air
Systemic Examination-
CVS- S1 S2 heard
RS- NVBS heard
PER ABDOMEN- soft , non tender
CNS- NFND
INVESTIGATIONS-
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-11000
PCV-41.6
RBC-4.69
Serum.urea-35
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
Ca-9.9
P-3.7
CUE-
Colour:pale
Albumin:+++
Pus cells:4-5
Epithelial cells:2-4
MP-NEGATIVE
MP STRIP - NEGATIVE
LFT:TB-0.73 ,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.7A/G: 1.35
RBS-114
SEROLOGY-NEGATIVE.
ECG-
Usg: 1.Mild gall bladder wall edema
2.grade 1 fatty liver
3.Borderline prostomegaly
PROVISIONAL DIAGNOSIS- VIRAL PYREXIA with thrombocytopenia.
TREATMENT-
1.IV Fluids RL/NS @ 100 ml/hr
2. Inj.zofer 4mg IV
3.Temperature monitoring
4.BP monitoring
5. Watch for bleeding manifestations
6.strict I/O charting.
7.GRBS MONITORING 6th hrly
SOAP NOTES DAY 1
ICU BED -3
S- COMPLAINTS OF GENERALIZED WEAKNESS
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA,
VITALS -
TEMPERATURE - 98
PULSE RATE - 70BPM
BLOOD PRESSURE -
110/70 MM OF HG SUPINE
110/70MM OF HG STANDING
RESPIRATORY RATE - 19
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM (11/3/22)
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-1100
PCV-41.2
RBC-4.69
Hemogram (12/3/22)
Hb-13.7
Tlc-6200
Plt-12000
Rbc-4.3
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
LFT:TB-0.73,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.5A/G: 1.35
RBS-114
SEROLOGY- HIV,HBSAG NEGATIVE.
Mp-negative
Mp strip- negative
A-VIRAL PYREXIA WITH THROMBOCYTOPENIA
P-
1.IVF NS,RL 100ML/HR
2.INJ.ZOFER 4 MG
3.TEMP/BP/GRBS MONITORING
SOAP NOTES DAY 2
ICU BED -3
S- COMPLAINTS OF GENERALIZED WEAKNESS
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA,
VITALS -
TEMPERATURE - 97.8
PULSE RATE - 70BPM
BLOOD PRESSURE -
110/70 MM OF HG SUPINE
110/70MM OF HG STANDING
RESPIRATORY RATE - 20
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM (11/3/22)
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-1100
PCV-41.2
RBC-4.69
Hemogram (12/3/22)
Hb-13.7
Tlc-6200
Plt-12000
Rbc-4.3
Hemogram (13/3/22)
Hb-13.8
Tlc-6500
Plt-12000
Rbc-4.47
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
LFT:TB-0.73,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.5A/G: 1.35
RBS-114
SEROLOGY- HIV,HBSAG NEGATIVE.
Mp-negative
Mp strip- negative
Cue(14/3/22)
Sugar-nil
Albumin-nil
Pus-2-3
Epithelial cells-1-3
A-VIRAL PYREXIA WITH THROMBOCYTOPENIA
P-
1.IVF NS,RL 100ML/HR
2.INJ.ZOFER 4 MG
3.TEMP/BP/GRBS MONITORING
SOAP NOTES DAY 3
ICU BED -3
S- GENERALIZED WEAKNESS subsided
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA,
VITALS -
TEMPERATURE - 97.6
PULSE RATE - 69BPM
BLOOD PRESSURE -
120/80 MM OF HG SUPINE
120/80MM OF HG STANDING
RESPIRATORY RATE - 17
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM (11/3/22)
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-1100
PCV-41.2
RBC-4.69
Hemogram (12/3/22)
Hb-13.7
Tlc-6200
Plt-12000
Rbc-4.3
Hemogram (13/3/22)
Hb-13.8
Tlc-6500
Plt-12000
Rbc-4.47
Hemogram (14/3/22)
Hb-14.3
Tlc-7100
Plt-45000
Rbc-4.71
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
LFT:TB-0.73,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.5A/G: 1.35
RBS-114
SEROLOGY- HIV,HBSAG NEGATIVE.
Mp-negative
A-VIRAL PYREXIA WITH THROMBOCYTOPENIA
P-
1.IVF NS,RL 100ML/HR
2.INJ.ZOFER 4 MG
3.TEMP/BP/GRBS MONITORING
SOAP NOTES DAY 4
AMC CUBICLE-1
S- GENERALIZED WEAKNESS subsided
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA,
VITALS -
TEMPERATURE - 97.6
PULSE RATE - 80BPM
BLOOD PRESSURE -
130/80 MM OF HG SUPINE
130/80MM OF HG STANDING
RESPIRATORY RATE - 17
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM (11/3/22)
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-1100
PCV-41.2
RBC-4.69
Hemogram (12/3/22)
Hb-13.7
Tlc-6200
Plt-12000
Rbc-4.3
Hemogram (13/3/22)
Hb-13.8
Tlc-6500
Plt-12000
Rbc-4.47
Hemogram (14/3/22)
Hb-14.3
Tlc-7100
Plt-45000
Rbc-4.71
Hemogram (15/3/22)
Hb-15
TLC-9000
PLT-1 LAKH
RBC-4.94
PCV-44.9
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
LFT:TB-0.73,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.5A/G: 1.35
RBS-114
SEROLOGY- HIV,HBSAG NEGATIVE.
Mp-negative
Mp strip- negative
Cue(14/3/22)
Sugar-nil
Albumin-nil
Pus-2-3
Epithelial cells-1-3
A-VIRAL PYREXIA WITH THROMBOCYTOPENIA
P-
1.IVF NS,RL 100ML/HR
2.INJ.ZOFER 4 MG
3.TEMP/BP/GRBS MONITORING
Comments
Post a Comment