40 year female with viral Pyrexia with thrombocytopenia

 40 y old female came to casuality with complaints of fever 5 days back (resolved) vomitings and loose stools since yesterday

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 5 days back. Then she developed high grade fever which is now resolved. She c/o vomitings since yesterday which were non bilious with food particles as content and loose stools 3-4 episodes, black stools and a few episodes of red stools.

No h/o hematuria, rashes on the body

No h/o burning micturition. 

Past history:

Not k/c/o DM, HTN, TB, asthma, epilepsy

Vitals: 

Temp: afebrile

PR: 110 bpm

BP: 100/60 mm hg

RR: 20 cpm

CVS: s1s2 heard

RS: BAE+ NVBS+

P/A: soft, non tender, bowels sounds heard

CNS: NFND

Investigations: 

HB: 6.8

Platelets: 4000 /cu mm

CUE: alb +++

S alb: 1.0

Diagnosis:

Viral pyrexia (resolved) with thrombocytopenia

With bloody diarrhoea secondary to dysentery? Hemorrhoids?

With anemia under evaluation

With thrombocytopenia

INVESTIGATIONS ON 25/9/2021

SURGERY REFERRAL NOTES-

On 26/9/2021

SOAP NOTES DAY ONE-

26/9/2021

ICU 3rd bed

Unit-5 case

S-fever,loose stools and vomitings resided.

In view of low platelet count,sdp transfusion was done yesterday

O-bp-130/80 mm hg

Pr-75 bpm

Rr-18 cpm

Temp-afebrile

Cvs-s1,s2 heard

Rs-BAE +,NVBS +

P/A - soft,non tender,bowel sounds heard

Cns-nfnd

A- viral pyrexia(resolved) with thrombocytopenia with bloody diarrhoea secondary to dysentery?haemorrhoids?with anaemia under evaluation with hypoalbuminemia.

P-IV fluids infusion @50 ml/hr

Oral fluids-2L

Inj.tranexa 500 mg iv sos

Inj.vit k 1 amp in 100 ml ns iv od

Inj.pan 40 mg iv od

Inj.optineuron 1 amp in 100 ml ns iv od

Egg whites 4/day

Tab.pcm 650 mg/po/sos

Inj.neomol 100 ml iv sos if temp greater than 101°F

BP,pr 4th hourly monitoring

Inj.piptaz 2.25 gm iv tid

Investigations-

 

SOAP NOTES-

On 30/9/2021

Ward case

SOAP NOTES-

S-patient has no new complaints 

O- pt is c/c/c

Bp-120/70mm hg

Pr-78 bpm

Rr-18

Cvs-s1, s2 heard

Resp-BAE +

Per abdomen-soft,non tender

Cns- nfnd

A- viral pyrexia(resolved) with thrombocytopenia with bloody diarrhoea 2° to thrombocytopenia with anaemia 2° to blood loss?, nutritional? with hypoalbuminea 2° to nephrotic syndrome with denovo diabetes type 2.

Plan of care-

Inj.pan 40 mg IV od

Inj.tranexa 500 mg IV sos

Oral fluids-2L

Inj .hai sc acc to grbs

Inj.optineuron 1 amp in 100 ml NS IV od

Tab.pcm 650 mg po sos

Grbs charting 6th hourly

Temp charting 4th hourly.