a case of 50 yr old male

50 yr old male came to casualty with c/o

Fever since 4days 

Generalized weakness since 4 days

Vomtings since 2 days

HOPI:-

patient was apparently asymptomatic 4 days back had his dinner and went to sleep and developed fever with body pains which on medication relieved till next day after lunch he developed vomiting non projectile food in content 

From last 2 days he had vomitings 3 episodes/day and high grade fever associated with chills and rigor , bodypains, headache

He got NS1 +ve in local hospital and later got presented in casuality

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema

Vitals:

Temp:99.5f

PR: 92 bpm, regular

RR: 26 cpm

BP: 100/70 mmHg

SPO2:

AT ROOM AIR-96%

GRBS:126 mg/dl

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

  Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A: obese, tenderness absent, bowel sounds heard

Cns: NFND

Diagnosis-

Dengue fever with thrombocytopenia

Treatment given

1. IVF NS,RL @150ML/Hr

2. Inj. Pantop 40mg IV/TID

3. Inj. Zofer 4mg/IV/SOS

4. Inj.Neomol 1gm/IV/SOS

5. T.PCM 650MG/TID

7. Check for postural hypotension/bleeding manifestations 2nd hrly

8. Temp charting

9. I/O Charting

Investigations:-

1.Sr.Electrolytes

       Na+. 139

       K+. 4.5

       Cl-. 96

2.Sr. Creatinine- 1.3

4. Hemogram

          Hb-13.8

          TLC-6300

          N-50

          L-40

          E-02

          B-00

          M-08

          PCV-39.2

          MCV -79.7

          MCH -28.0

          RBC.-4.92

          PLT-38,000

5. Blood urea-63

6. RBS-83

7. Dengue NS1 -positive

8. LDH-357

9. BGT-O+ve

10. APTT-32Sec

11. ESR-10

12. PT-15sec

Day 1

SUBJECTIVE

No fever spikes 

No subjective complaints

Objective

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy

Vitals:

Afebrile

PR: 44 bpm, regular

RR: 20 cpm

BP: 110/70 mmHg with NA@6ml/hr

SPO2:

AT ROOM AIR-98%

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

  Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A: soft, tenderness present at rt lumbar and rt hypochondrium

Cns: No focal deficit

Assessment-

Viral Pyrexia with thrombocytopenia with serositis

Plan

1. IVF NS,RL @150ML/HR

2. INJ. PANTOP 40MG IV/OD

3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)

4. Tab.PCM 650MG PO/TID

5. Bp monitoring

6. W/F bleeding manifestations

7. Temp & I/O charting

ECG:

USG ABDOMEN

1. MILD B/L PLEURAL EFFUSION

2. MILD GALL BLADDER WALL OEDEMA(F/S/O SEROSITIS)

Day 2

SUBJECTIVE

No fever spikes 

No subjective complaints

Objective

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy

Vitals:

Afebrile

PR: 56 bpm, regular

RR: 20 cpm

BP: 110/70 mmHg with NA@6ml/hr

SPO2:

AT ROOM AIR-98%

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

  Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A: soft, tenderness present at rt lumbar and rt hypochondrium

Cns: No focal deficit

Assessment-

Viral Pyrexia with  thrombocytopenia with serositis

Plan

1. IVF NS,RL @150ML/HR

2. INJ. PANTOP 40MG IV/OD

3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)

4. Tab.PCM 650MG PO/TID

5. Bp monitoring

6. W/F bleeding manifestations

7. Temp & I/O charting

 ECG:

2D -ECHO

Day 3 

SUBJECTIVE

No fever spikes 

No subjective complaints

Objective

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy

Vitals:

Afebrile

PR: 48 bpm, regular

RR: 20 cpm

BP: 110/70 mmHg with NA@6ml/hr

SPO2:

AT ROOM AIR-98%

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

  Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A: soft, tenderness present at rt lumbar and rt hypochondrium

Cns: No focal deficit

Assessment-

Viral Pyrexia with  thrombocytopenia with serositis

Plan

1. IVF NS,RL @150ML/HR

2. INJ. PANTOP 40MG IV/OD

3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)

4. Tab.PCM 650MG PO/TID

5. Bp monitoring

6. W/F bleeding manifestations

7. Temp & I/O charting

A case of 60yr old male

A 60yr/M came to the casualty with complaints of 

Fever(since 1 week)

Cough(since 1 week)

SOB(since 2 days)

Patient was apparently asymptomatic 1 week back and developed fever associated with chills and rigor,dry cough, general weakness, No diurnal variation. He has also been experiencing dyspnea on exertion, Grade 3, since 2 days

There was history of similar complaints inthe past where fever was associated with hematemesis(acc. To patient attender) due to which he was admitted to a hospital in kodad and got treated

He was diagnosed as diabetes since 3 years(through a camp) and is on regular medication

Personal history

1. Married

2. Decreased appetite

3. Vegetarian

4. Normal bowel and bladder

5. Was a alcoholic(90ml/day) and smoker (1 pack/day) 11yrs back

No significant family history

No significant drug history

O/E

Pt is c/c/c

Vitals:

BP: 100/50mmhg

PR: 90/min

SpO2:91%@RA

GRBS: 159mg/dl

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

 Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A : soft , Non-tender

Provisional diagnosis

Viral Pyrexia (RTPCR+VE FOR COVID-19)

Investigations:-

1.Sr.Electrolytes

       Na+. 141

       K+. 4.4

       Cl-. 106

2.Sr. Creatinine- 1.5

3.LFT

  Tb-1.20

  Db-0.42

  Ast-120

  Alt-56

  Alp-83

  TP-4.8

  ALBUMIN-2.5

  A/G- 1.64

4. Hemogram

          Hb-11.7

          TLC-9500

          N-56

          L-11

          E-02

          B-00

          PCV-46.5

          MCV -79.4

          MCH -27.2

          RBC.-5.86

          PLT-1.65L

5. uric acid-5.0

6. RBS-148

7. Cr. Cl -11ml/hr

8. RTPCR (COVID-19) - +VE

9. 2D -Echo

10. X-Ray

Treatment Given:

1) INJ. AUGMENTIN 1.2gm IV/BD

2) IVF RL &NS @ 150 mL/hr

3) HEAD END FLEVATION

4) 0₂ INHALATION TO MAINTAIN SpO2≥94%

5 INJ.PANTOP 40mg IV/OD

6) INJ. NEOMOL 1.9m Iv/sos (If Temp>100f)

7) TAB.AZEE 500mg PO/OD

8) TAB PCM 650mg Po/TID.

9) NEB WITH BUDECORT - 6th HRLY DUOLIN - 8th HRLY

10) INI HAI ACC TO SLIDING SCALE

Patient was referred to higher center I/V/O RTPCR+ve for covid-19

Case of 17y/M with viral pyrexia(NS1+ve) and thrombocytopenia

17 yr old male came to casualty with c/o

Fever since 4days 

Generalized weakness since 4 days

Vomtings since 3 days

HOPI:-

patient was apparently asymptomatic 4 days back had his dinner and went to sleep and developed fever with body pains which on medication relieved till next day after lunch he developed vomiting non projectile food in content and later got fever 

From last 2 days he had vomitings 3 episodes/day and high grade fever associated with chills and rigor , bodypains, headache, and weakness after he went to the local rmp where he prescribed saline infusion

Today in the morning he had 2 episodes of vomitings and presented to the casualty

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema

Vitals:

Afebrile

PR: 92 bpm, regular

RR: 26 cpm

BP: 100/70 mmHg

SPO2:

AT ROOM AIR-96%

GRBS:126 mg/dl

Systemic examination :

 CVS:S1,S2 heard

  Apex beat:5th ICS

  Resp:

  BAE+(vesicular breath sounds)

  Nvbs heard

  Position of trachea- central

P/A: obese, tenderness absent, bowel sounds heard

Cns: NFND

Diagnosis-

Dengue fever with thrombocytopenia

Treatment given

1. IVF NS,RL @150ML/Hr

2. Inj. Pantop 40mg IV/TID

3. Inj. Optineuron 1amp in 100ml NS slow IV/OD

4. Syp. Mucaine gel 10ml-10ml-10ml

5. Check for postural hypotension/bleeding manifestations 2nd hrly

6. Temp charting

7. I/O Charting

Investigations:-

1.Sr.Electrolytes

       Na+. 139

       K+. 4.9

       Cl-. 99

2.Sr. Creatinine- 0.9

3.LFT

  Tb-1.04

  Db-0.24

  Ast-112

  Alt-40

  Alp-261

  TP-5.9

  ALBUMIN-3.5

  A/G- 1.49

4. Hemogram

          Hb-16.4

          TLC-2900

          N-50

          L-40

          E-02

          B-00

          PCV-47.5

          MCV -86.2

          MCH -30.3

          RBC.-5.51

          PLT-20,000

5. Blood urea-20

6. RBS-83

7. Dengue NS1 -positive

       Petechiae on left side of chest

Buccal mucosa petechiae

Ecg

USG Abdomen

1. Gb wall thickness increased

2. Mild free fluid in perihepatic space

3. Minimal free fluid in pelvis

SOAP NOTES DAY 2

ICU 2nd BED

A 17Y/M with viral pyrexia

DAY -2

SUBJECTIVE -

no complaints of fever 

C/O abdominal pain 

C/O vomitings ( 1 episode)

OBJECTIVE-

pt is c/c/c

Temp :98F

BP Supine-120/80

standing 

1 min - 110/70

3 min - 100/70

PR:67bpm

CVS:S1S2+

Respiratory:BAE+

P/A 

soft

tenderness in epigastric and right hypochondriac region 

no palpable mass

Assesement : Viral pyrexia with thrombocytopenia (NS1 +ve)

PLATELET COUNT ON 19/9/21 -26,000

Plan of care :

1. IVF NS/RL @ 150ml/hr 

2.INJ.PANTOP 40 MG IV/OD

3.INJ.ZOFER 4 MG IV /SOS

4.INJ OPTINEURON 1 AMP IN 100ML NS SLOW IV/OD

5.TAB.PCM 500MG PO/SOS

6.SYP.MUCAINE GEL 15ml PO/TID

7.SYP CREMAFFIN PLUS 150ML/PO/TID

8.TEMP AND I/O CHARTING 

9.CHECK FOR POSTURAL HYPOTENSION

Platelet transfusion done(7.00pm)

 

Day3

SOAP NOTES

ICU 2nd BED

A 17Y/M with viral pyrexia

DAY -2

SUBJECTIVE -

no complaints of fever 

C/O abdominal pain 

C/O itching on rt hand (decreased intensity compared to yesterday)

OBJECTIVE-

pt is c/c/c

Temp :98F

Bp

Supine-120/80

standing 

3 min - 90/70

PR:67bpm

CVS:S1S2+

Respiratory:BAE+

P/A 

soft

tenderness in epigastric and right hypochondriac region 

no palpable mass

Assesement : Viral pyrexia with thrombocytopenia (NS1 +ve)

PLATELET COUNT ON 21/9/21 -40,000

Wbc-3700

Plan of care :

1. IVF NS/RL @ 150ml/hr 

2. 2.INJ.PANTOP 40 MG IV/OD

3. 3.INJ.ZOFER 4 MG IV /SOS

4. 4.INJ OPTINEURON 1 AMP IN 100ML NS SLOW IV/OD

5. 5.TAB.PCM 500MG PO/SOS

6. 6.SYP.MUCAINE GEL 15ml PO/TID

7. 7.SYP CREMAFFIN PLUS 150ML/PO/TID

8. 8.TEMP AND I/O CHARTING 

9. 9.CHECK FOR POSTURAL HYPOTENSION