65 year old female with Pyrexia with thrombocytopenia

 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 

Chief complaints: 

fever since 4 days 

Body pains since since 3 days 

B/L LL pain since 2 days 

Abdominal pain since morning 

Loose stools 4-5 times since morning 

Vomiting (bilious) 1 episode since morning 

HOPI:

Pt was apparently asymptomatic 4 days back then had fever associated with chills and rigors which is continuous only relieved on medication (high grade ) not associated with cold, cough ,burning micturition. Fever associated with body pains and headache with no diurnal variation.Then had abdominal pain since morning with loose stools 4-5 times since morning and vomitings 1episode which is bilious (no food particles)not associated with nausea 

PAST HISTORY:

k/c/o: Hypertension since 4 years 

(using Telmi 20 mg PO/OD )

N/K/C/O: DM, TB, Epilepsy,CAD,Asthma,Thyroid

PERSONAL HISTORY :

Diet :mixed 

Appetite:normal

Sleep: Adequate 

B/B movements: Regular

Addictions:No addictions

GENERAL EXAMINATION:

Patient Is conscious coherent and co operative and well oriented to time place and person

No  pallor, ictreus , clubbing, cyanosis, lymphadenopa And Edema

Temp : 98.4

PR:84bpm

BP:110/70mmHg

RR: 16 cpm

CVS:S1S2+

RS:BAE+

CNS:NAD

P/A: soft , non tender, no organomegaly

INVESTIGATIONS:

NS1 Antigen -positive

Ig-M and Ig-G -negative 










 
USG -Abdomen 22/11/22






Hemogarm

21/11/22.      22/11/22.     23/11/22.    24/11/22.     25/11/22

Hb: 12.7.         12.5             12.4            11.7              10.9

TLC:3410      2550              2800           3310             4300

PLT: 30000      36000          24000(M)   36000(M)    70000

                                             14000(N)    26000(N)             

DIAGNOSIS: viral pyrexia with thrombocytopenia 

TREATMENT:

1.IVF NS @100 ml / hr

2.T.DOLO 650 mg PO/SOS

3.T.SPOROLAC -DS 120 mg PO/TID

4. INJ. OPTINEURON 1amp in 100 ml NS IV /OD

5.INJ. NEOMOL 1gm IV/SOS

6. BP MONITORING 4th HRLY

7.VITALS MONITORING 4th HRLY

8. TEMPERATURE MONITORING 4th HRLY




         





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