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A case of 15 yr old male

This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

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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