VIRAL PYREXIA with THROMBOCYTOPENIA & AKI

A 55 yr old  male patient came to casualty with complaints of fever since 3 days, which was intermittent, low grade & associated with chills , decreased with treatment
C/O cough with expectoration since 3 days
? Hemoptysis (scanty) today evening
H/O 5-6 episodes of loose stools ( watery, no mucous/ blood) 3days back which resolved with treatment
No H/O nausea, vomiting
No H/O pain abdomen, cold ,SOB
No H/O rash/bleeding gums/reddish discoloration of urine
No other complaints
Pt  first went to a local hospital and then they refer here to our hospital in V/O low platelet count ( 12000)
Past history :
No H/O DM, HTN, asthma, epilepsy, CAD
H/O ? TB 10 yrs back - used ATT for 4 months
H/O ? Pneumonia & some kidney issue ? AKI 2 months back (no records available)
Personal history :
Mixed diet
Decreased appetite
Regular B&B
Addictions: Regular alcoholic & smoker (beedi) since 40 yrs
Family history - not significant
On examination -
Pt is C/C/C
Temp - 99.5 F
BP -80/50 mmhg
PR -78 bpm
RR -20 CPM
No pallor , icterus , cyanosis,  clubbing , lymphadenopathy
On systemic examination :
CVS : S1 S2 + , no thrills
RS : BAE + , NVBS
P/A: Soft , NT
CNS : pt is conscious
Speech : normal
No signs of meningeal irritation
Motor & sensory system normal
Reflexes present
Cranial nerves intact
Diagnosis : Dengue NS1+ with thrombocytopenia
AKI

Unit 6
A case of 55 /male
SOAP NOTES:day 1
S : FEVER spike +
O : O/E
Pt is C/C/C
Temp :100.1F
BP : 110/60 mmhg
PR :58 bpm
CVS : S1S2 +
RS :BAE +
CNS :NFD
P/A : soft , nontender
BS +
A : Dengue fever ( NS1 possitive)
      AKI with serositis
P :
1. IVF - NS,RL  - @150 ml/ HR
2. Inj pan 40 mg IV / OD
3. Inj optinuron 1 amp in 100 ml NS
4.Inj neomol 1 GM IV SOS
5. Tab Solo 650 mg TID
6. BP,PR, temp charting
7. Postural BP monitoring daily
8. Inj noradrenaline infusion 1 ml / hr

SOAP NOTES:day 3
S :  no fresh complaints
O : O/E
Pt is C/C/C
Temp :99.5F
BP : 130/80 mmhg
PR :62 bpm
CVS : S1S2 +
RS :BAE +
CNS :NFD
P/A : soft , nontender
BS +
A : Dengue fever ( NS1 possitive)
      AKI with serositis
P :
1. IVF - NS,RL  - @150 ml/ HR
2. Inj pan 40 mg IV / OD
3. Inj optinuron 1 amp in 100 ml NS
4.Inj neomol 1 GM IV SOS
5. Tab Dolo 650 mg TID
6. BP,PR, temp charting
7. Postural BP monitoring daily
8. Inj noradrenaline infusion 1 ml /Unit 6

SOAP NOTES:day 4
S :  fever reduced
O : O/E
Pt is C/C/C
Temp :97.2 F
BP : 100/60 mmhg
PR :54 bpm
CVS : S1S2 +
RS :BAE +
CNS :NFD
P/A : soft , nontender
BS +
A : Dengue fever ( NS1 possitive)
      AKI with serositis
P :
1. IVF - NS,RL  - @150 ml/ HR
2. Inj pan 40 mg IV / OD
3. Inj optinuron 1 amp in 100 ml NS
4.Inj neomol 1 GM IV SOS
5. Tab Dolo 650 mg TID
6. BP,PR, temp charting
7. Postural BP monitoring daily
8. Inj noradrenaline infusion 1 ml / hr
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