A 50 year old man with viral pyrexia with mild thrombocytopenia and RVD positive
Date of admission : 26/8/21:
A 50 year old male who is a shepherd by occupation came to the causality with chief complaints of fever since 20 days,sob at rest since 20 days,decreased appetite since 20 days ,vomitings since 10 days
HOPI- Patient was apparently asymptomatic 2 months back,then he had developed pain in right flank region which was pricking type of pain,radiating to loin and was relieved on medication
The patient also similar complaints in the past which was around 5-6years ago
C/O shortness of breath on Exertion which was of grade 1-2,gradually progressed to sob at rest of grade 3-4
No complaints of Orthopnea,PND
C/o fever since 20 days associated with chills and rigors which was On and off and had lasted for 2 hours
C/o cough since 20 days associated with sputum which is whitish,mucoid,non blood tinged and is of less quantity
C/o chest pain which was pricking type,aggravated on coughing
C/o nausea,vomiting since 10-15 days which is associated with food particles,non bilious,not associated with blood
No c/o palpitations,syncopal attacks
No c/o pedal edema,facial puffiness,decreased urine output,burning micturition
Personal history-
Diet-mixed
Appetite - lost
Bowel and bladder-regular
Addictions-non-smoker and non-alcoholic
Family history- not significant
General examination-
Patient is conscious,coherent,cooperative
He is oriented to time,place,person
Pallor-no
Icterus-no
Cyanosis -no
Clubbing -no
Lymphadenopathy -no
Vitals at the time of presentation-
Bp-90/60mmHg
PR-88bpm
RR-24cpm
Spo2-92% at room air
Grbs-97mg/dl
Systemic examination-
CVS-S1S2 heard,no murmurs and thrills
Respiratory system-dyspnea and wheeze are present
Inspiratory crepts are noted all over chest
Abdomen-soft and tenderness is present in umbilical region
Bowel sounds present
CNS-NAD
Provisional diagnosis:
Viral pyrexia with mild thrombocytopenia and RVD positive
Investigations-
On 26/8/21:
Hb-12.4
TLC-4,000
Platelets-1.2lakh
PCV-34.6
MCV-85.6
CUE-
Albumin-trace
Sugars-nil
Pus cells-3 to 4
Malarial parasite-negative
RBS-73
Creatinine-1.1
Urea-52
Sodium -139
Potassium-4.4
Chloride-102
Uric acid-5.57
Total bilirubin-2.27
Direct bilirubin-0.47
AST-15
ALT-10
Total proteins-5.9
Albumin-3.2
A/G ratio-1.20
HIV-Positive
HbsAg-negative
Hcv-negative
Dengue NS1 antigen-negative
RTPCR: Negative
Chest XRAY:
On 27/8/21:
Hemogram:
Hb: 11.3 gm/dl
Rbc: 3.68 millions/cumm
TLC: 3200 cells/cumm
Pcv: 31.9
PLT : 1.5 lakhs/cumm
APTT: 35 sec
PT: 17 sec
INR: 1.25
BGT: B POSITIVE
2d echo:
ON 28/8/21:
HEMOGRAM:
Hb: 12.8 gm/dl
RBC: 4.13
TLC: 3500
PCV: 35.9
PLT: 1.04
TB: 1.29
DB : 0.40
On 29/8/21:
Hb:13.0
TLC: 3400
PLT: 1.05
On 30/8/21:
Hemogram:
Hb- 12.8
TLC- 3100
RBC-4.18
PLT- 1.10
On 31/08/21:
Hemogram:
Hb-13.0
TLC- 3800
RBC- 4.18
PLT- 1.07
Chest xray:
Treatment given:
On Day 0:
1.IV fluids Ns, Rl @ 100ml/hr
2. Inj. Zofer 4 mg iv bd
3. Inj. Pan 40 mg iv od
4. Inj. Optineuron 1 amp in 100ml Ns IV od
5. Temp/Bp/ PR / RR 4 the hrly
6. Tepid sponging 4th hrly
7. Strict I/O charting
On Day 1:
1.IV fluids Ns, Rl @ 100ml/hr
2. Inj. Zofer 4 mg iv bd
3. Inj. Pan 40 mg iv od
4. Inj. Optineuron 1 amp in 100ml Ns IV od
5. Temp/Bp/ PR / RR 4 the hrly
6. Strict I/O charting
7. Nebulisation with Budecort, duolin, mucomist 6th hrly
Day 2:
1.IVF NS, RL @ 100 ml/hr
2. Inj. Pan 40 mg IV od
3. Inj. Zofer 4 mg iv bd
4. Inj Optineuron 1 amp in 100 ml NS IV OD
5. Strict I/O charting
6. Nebulisation with duolin , budecort, mucomist 6th hrly
7. Monitor vitals
8. Inj. Ceftrioxone 1 gm iv bd
9. Tab. Septran -ds po tid
Day 3:
1. IV fluids NS , RL @ 100 ml/ hr
2. Inj. Zofer 40 mg iv bd
3. Inj. Pan 40 mg iv od
4. Inj. Optineuron 1 amp in 100 ml NS iv OD
5.Tab septran ds (160/800) po tid
6. Inj. Ceftrioxone 1 gm iv bd
7. Tab cetrizine 5 mg po bd
8. Syp. Ambroxyl 5 ml po tid
9. Nebulisation with duolin, budecort, mucomist 6th hrly
Day 4:
1. IV fluids NS , RL @ 100 ml/ hr
2. Inj. Zofer 40 mg iv bd
3. Inj. Pan 40 mg iv od
4. Inj. Optineuron 1 amp in 100 ml NS iv OD
5.Tab septran ds (160/800) po tid
6. Inj. Ceftrioxone 1 gm iv bd
7. Tab cetrizine 5 mg po bd
8. Syp. Ambroxyl 5 ml po tid
9. Nebulisation with duolin, budecort, mucomist 6th hrly
10. Bp /PR/spo2 /Temp charting
Day 5:
1. IV fluids NS , RL @ 100 ml/ hr
2. Inj. Zofer 40 mg iv bd
3. Tab pcm po tid
4. Inj. Optineuron 1 amp in 100 ml NS iv OD
5.Tab septran ds (160/800) po tid
6. Inj. Ceftrioxone 1 gm iv bd
7. Tab cetrizine 5 mg po bd
8. Syp. Ambroxyl 5 ml po tid
9. Nebulisation with duolin, budecort, mucomist 6th hrly
10. Bp /PR/spo2 /Temp charting
11. Inj. Neomol sos if temp >101 F
