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