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This E-log is presented under the guidance of Dr.Sriram(intern)
Note:This is an ongoing case and will be updated regularly.
Date of admission: 11/08/2021
A Case of 15 yr old male with viral pyrexia and thrombocytopenia
CHIEF COMPLAINTS:
15 year old male ,came to the casuality with chief complaints of
▪︎Fever since 4 days
▪︎Giddiness since 4 days
▪︎Vomitings : 3 episodes since yesterday.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4 days back.
Then he developed fever (high grade fever associated with chills), generalised body pains and headache for which he went to local RMP and received treatment(ceftriaxone injection) but the fever didn't subside and so he was referred here.
▪︎H/o giddiness since 4 days was present.
▪︎ H/o Vomiting since yesterday - 3 episodes, non bilious,containing food particles, no blood stains present and not foul smelling
▪︎No h/o pain in abdomen
▪︎No h/o loose stools
▪︎No h/o cold, cough and SOB
▪︎No h/o Melena
▪︎No h/o burning micturition
PAST HISTORY:
Not a k/c/o DM, HTN, Asthma,CVA,CAD, thyroid and epilesy
PERSONAL HISTORY:
▪︎Diet - Mixed
▪︎Sleep - Adequate
▪︎Appetite - Decreased
▪︎Bowel & bladder movements - Increased
▪︎No addictions present
DRUG HISTORY:
Patient was given Inj.ceftriaxone for complaints of high grade fever associated with chills, generalised body pains and headache at RMP.
GENERAL EXAMINATION:
No pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema.
Vitals:
▪︎Temp:101°F
▪︎PR:96 BPM.
▪︎RR:18 CPM.
▪︎BP:110/80 mm Hg
▪︎SPo2 :98% @ room temperature
▪︎GRBS:128 MG%.
SYSTEMIC EXAMINATION:
CVS:
Inspection:
▪︎Chest wall is bilaterally symmetrical.
▪︎No precordial bulge
▪︎No visible pulsations, engorged veins, scars, sinuses
Palpation:
▪︎JVP: normal
▪︎Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscultation
▪︎S1,S2 heard
No murmurs
Respiratory system:
▪︎NVBS heard
▪︎BAE present
▪︎Trachea:Central
Per abdomen:
▪︎Soft,Non tender,Non distended, No Organomegaly
▪︎Bowel sounds present
▪︎No palpable mass or free fluid
CNS:
▪︎Speech is normal
▪︎No signs of meningeal irritation
▪︎Motor and Sensory system:Normal
▪︎Cranial nerves:Intact
▪︎Reflexes:
RT. LT.
BICEPS +2 +2
TRICEPS +2 +2
SUPINATOR +2 +2
KNEE +2 +2
ANKLE +2 +2
PLANTAR: Flexor
INVESTIGATIONS:
ECG
CHEST X-RAY
RANDOM BLOOD SUGAR
BLOOD UREA
SERUM CREATININE
SERUM ELECTROLYTES
DENGUE NS1 ANTIGEN TEST
HEMOGRAM
BLOOD GROUPING AND RH TYPE
COMPLETE URINE EXAMINATION
MALARIAL STRIP TEST
ULTRA SOUND REPORT
FEVER CHART(from 12/08 to 16/08)
12/08/2021
HEMOGRAM
SERUM ELECTROLYTES
13/08/2021
HEMOGRAM
SERUM ELECTROLYTES
16/08/2021
HEMOGRAM
PROVISIONAL DIAGNOSIS:
▪︎Viral pyrexia with thrombocytopenia
TREATMENT:
Day 1
1. IVF 2 NS, @ 75 ml/hr
2. Inj . ZOFER 4mg /iv/sos
3. Tab PCM 500 mg PO/TID
4. Inj NEOMOL 100 ml /iv/sos if temp >101 F
5. Temperature charting 4th hourly
6. W/F Bleeding manifestation
7. Tab pan 20 mg PO/BD
Day 2
SUBJECTIVE :
C/o black coloured stools
OBJECTIVE :
Temperature - 98.6 F
BP - 100/60 mm hg (supine)
- 120/100 mm hg (standing)
PR - 72 bpm
RR - 17 cpm
GRBS - 106 mg/dl
Treatment
1. IVF - 1 DNS with 1 amp optineuron @75 ml/hr, 1 NS & 1 RL @ 75 ml/hr
2. Tab pcm 500 mg /sos
3. Tab pan 20 mg /po/od
4. W/F bleeding manifestation
5. Bp & Temp charting 4th hourly
Day 3
Treatment
1. Plenty of oral fluids
2. IVF 1 NS, 1 RL , 1 DNS @ 50 ml/hr
3. Tab pcm 500 mg po/sos
4. W/F bleeding manifestation
5. Check postural hypotension
6. PR/BP Charting 4th hourly
Day 4
Treatment
1. Plenty of oral fluids
2. IVF 1 NS, 1 RL , 1 DNS @ 50 ml/hr
3. Tab pcm 500 mg po/sos
4. W/F bleeding manifestation
5. Check postural hypotension
6. PR/BP Charting 4th hourly
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