A 16 yr old female with viral pyrexia

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Unit 6 admission

AMC case Bed 4

A 16 year old female came to casualty with cheif complaints of fever since 1 week,headache since 2 days ,dry cough since 2 days.

She was apparently assymptomatic 1 week ago then she developed fever ,which is intermittent ,not associated with chills and rigors. They went to a local hospital and took medication for fever and fever got subsided and was recurring again. later she developed dry cough and headache since 2 days.Not associated with vomitings ,loose stools.No bleeding manifestations,no burning micturition.

PAST HISTORY

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

PERSONAL HISTORY

student 

Takes mixed diet

Appetite - normal

Sleep - adequate

Bowel and bladder movements - regular

No known addictions and allergies

GENERAL PHYSICAL EXAMINATION

Pt is conscious, coherent, cooperative

Moderately built and nourished

No pallor ,icterus, clubbing ,cyanosis  lymphadenopathy,odema of feet.

Vitals

Temp-104°F

Pr- 132 BPM

Bp- 70/50 mm hg

Rr - 20 cpm

Grbs-97mg/dl

SYSTEMIC EXAMINATION

Cvs- S1,S2 

Rs - BAE+, NVBS+

P/a - soft ,nontender,bowel sounds +

2D ECHO

Provisional diagnosis

Viral pyrexia with thrombocytopenia under evaluation

Soap notes

ICU BED 5

S:

No Fever spikes present.

No hematuria,No melena,NoGiddiness

O

Throboplebitis+,petechiae+ 

Patient c/c/c

Bp

supine:110/70mm hg

Standing:110/70mm hg

Temp:98 F

Pr:124bpm

Rr:17cpm

Cvs:s1,s2 heard

Rs:BAE+

Per abdomen:soft,non tender

A:

VIRAL PYREXIA WITH THROMBOCYTOPENIA

P:

1.IVF- RL,NS @ 50 ml/ hr

2.inj.NEOMOL 1GM IV SOS

3.Inj.PAN 40MG

4.SYP.ASCORIL 10ML PO/SOS

5.BP/TEMP MONITORING 4TH HRLY

6.THROMBOPHOBE OINT FOR L/A

7.TAB.DOLO 650MG PO/SOS

8.INFORM SOS

Soap notes Day 3

A 16 yr old female

ICU BED 5

S:

 No Fever spikes present.

No hematuria,No melena,NoGiddiness

O

Throboplebitis+,petechiae+ 

Patient c/c/c

Bp : 120/80 mmHg

Temp:99.5 F

Pr: 78 bpm

Rr:17cpm

Cvs:s1,s2 heard

Rs:BAE+

Per abdomen:soft,non tender

A:

VIRAL PYREXIA WITH THROMBOCYTOPENIA

P:

1.IVF- RL,NS @150ml/hr

2.inj.NEOMOL 1GM IV SOS

3.Inj.PAN 40MG

4.SYP.ASCORIL 10ML PO/SOS

5.BP/TEMP MONITORING 4TH HRLY

6.THROMBOPHOBE OINT FOR L/A

7.TAB.DOLO 650MG PO/SOS

8.INFORM SOS

http://mounika107.blogspot.com/2021/11/a-16-yr-old-female-with-viral-pyrexia.html

Soap notes Day 4

AMC  bed 4 ,

A 16 yr old female

S:

 No Fever spikes present.

No hematuria,No melena,NoGiddiness

O

Throboplebitis+,

Patient c/c/c

Bp : 100/60 mmhg

Temp:98.6 F

Pr: 88 bpm

Rr:17cpm

Cvs:s1,s2 heard

Rs:BAE+

Per abdomen:soft,non tender

A:

VIRAL PYREXIA WITH THROMBOCYTOPENIA

P:

1)Inj.PAN 40MG

2)SYP.ASCORIL 10ML PO/SOS

3).BP/TEMP MONITORING 4TH HRLY

4).THROMBOPHOBE OINT FOR L/A

5).TAB.DOLO 650MG PO/SOS

6 )INFORM SOS

http://mounika107.blogspot.com/2021/11/a-16-yr-old-female-with-viral-pyrexia.html