VIRAL PYREXIA WITH THROMBOCYTOPENIA

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A 30 yr old male/farmer by occupation,

Patient came with c/o fever with chills since 4 days intermittent, subsided yesterday. 

c/o nausea , burning micturation since 2 days 

c/o SOB since 2 days

c/o pain abdomen since 2 days 

 

HOPI: 

Patient was apparently asymptomatic 4 days back later developed fever with chills , intermittent and subsided yesterday.

Patient c/o nausea and burning micturation,and sob since 2 days and not a/w sputum/cough.

No c/o loose motion/vomiting.

patient c/o pain abdomen since 2 days.

PAST HISTORY : 

History of TM perforation 3 yrs ago - Treatment- with medication

N/K/C/O    HTN/DM/TB/EPILEPSY/CAD 

O/E : Patient is C/C/C 

No Pallor /Icterus /Cyanosis /Edema of feet  /Lymphadenopathy /Clubbing-

VITALS :  

Temp :  98.5  F 

PR : 72 bpm

BP : 110/80 mmhg 

RR : 18 cpm

SPO2 : 99 % at RA 

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : Bilateral air entry present ,  clear 

CNS : NAD 

PA :  diffuse tenderness+

PROVISIONAL DIAGNOSES:-

VIRAL PYREXIA WITH THROMBOCYTOPENIA 

TREATMENT given on day 1

1)IVF NS ,RL @ 150 ml/hr and

 DNS @100 ml/hr

2)PANTOP 4O MG iv /od

3)Inj. NEOMOL 1gm sos IV.

4)Inj. OPTINEURON 1 amp in 100 ml NS iv/od

5)Tab. DOLO 650mgPO SOS

6)Plenty of oral fluids

7)WIF POSTURAL HYPOTENCION

8) WIF BLEEDING MANIFESTATIONS

CBP ON 17/3/22

BGT- O POSITIVE

VIRAL SEROLOGY - NEGATIVE

NS1 ANTIGEN- Negative

IgM- Negative

IgG- negative

On 18/3/22 early morning 1 unit of SDP transfusion done

CBP ON 18/3/22

SOAP NOTES ON 19/3/22

 

S:c/o Malena

O: pt is conscious/coherent

Afebrile

BP: 120/80 mmHg

PR.103 bpm

RR:18 cpm

CVS:S1S2 +

RS: BAE+

A: VIRAL PYREXIA WITH THROMBOCYTOPENIA

P:1)IVF NS ,RL @ 100 ml/hr 

2)PANTOP 4O MG iv /od

3)Inj. NEOMOL 1gm sos IV.

4)Inj. OPTINEURON 1 amp in 100 ml NS iv/od

5)Tab. DOLO 650mgPO SOS

6)Plenty of oral fluids

7)INJ.ZOFER 4 MG IV/BD

8)WIF POSTURAL HYPOTENCION

9) WIF BLEEDING MANIFESTATIONS

10) BP,PR,SPO2  MONITORING

CBP ON 19/3/22