35/M viral pyrexia with thrombocytopenia (dengue NS1)

MEDICINE CASE DISCUSSION

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

CASE SCENARIO 

A 35 yr old male presented with 

Fever since 5 days.

Loose stools 4 days back.

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic five days ago, then he developed fever which was low grade, intermittent, relieved on taking medication, not associated with chills and rigor.

C/o loose stools- 6 episodes, non-watery, not blood stained, four days ago which has subsided now.

No h/o vomitings, pain abdomen

No h/o chest pain, palpitations, SOB

No h/o cold, cough

No h/o bleeding manifestations, purpura, bleeding gums

His platelet count as per outside reports:

19th: 64,000

20th: 11am: 30,000

           6 pm: 25,000

21st: 12,000

PAST HISTORY:

Not a k/c/o DM, HTN, Br Asthma, TB, epilepsy, CAD, thyroid

PERSONAL HISTORY:

Married

Occupation: Farmer

Appetite: normal

Diet: mixed

Sleep: reduced

Bladder and bowel movements: regular

Addictions: occasional alcohol drinker

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION:

The patient was c/c/c

Afebrile

Moderately built and nourished

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy

BP:  Supine: 120/70mm Hg

        Standing: 1 min - 120/90 mm Hg

                         5 min - 110/80 mm Hg

PR:  96/min

SYSTEMIC EXAMINATION:

CVS :

 S1S2 HEARD 

no thrills no murmurs

P/A:

Non distended

Diffuse tenderness absent 

Guarding and rigidity absent

CNS: 

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact

INVESTIGATIONS:

— Chest Xray

— ECG

— USG abdomen

— Hemogram

    Day zero:

   Hb: 15.0%

   TC: 4100

   Platelets: 22,000

    Day one:

 Day two:

— Blood group : O+ve

— MP strip : negative

— Rapid dengue

— LFT

— RBS: 127 mg/dl

— Serum creatinine: 0.8 mg/dl

    Blood urea: 12 mg/dl

— Serum electrolytes

PROVISIONAL DIAGNOSIS: Viral Pyrexia with Thrombocytopenia - Dengue NS1

TREATMENT:

Day zero:

1) Plenty of oral fluids

2) IVF - 2.NS, 2.RL @ 75ml/hr

3) Inj. PANTOP 40 mg IV OD

4) Tab. PCM 650 mg PO TID

5) Temp charting 4th hrly and Tepid sponging

6) W/F Bleeding manifestations, postural hypotension

Day one:

1) Plenty of oral fluids

2) IVF - 2.NS, 2.RL @ 75ml/hr

3) Inj. PANTOP 40 mg IV OD

4) Tab. PCM 650 mg PO TID

5) Temp charting 4th hrly and Tepid sponging

6) W/F Bleeding manifestations, postural hypotension

Day two:

1) Plenty of oral fluids

2) IVF - 2.NS, 2.RL @ 75ml/hr

3) Inj. PANTOP 40 mg IV OD

4) Tab. PCM 650 mg PO TID

5) Temp charting 4th hrly and Tepid sponging

6) W/F Bleeding manifestations, postural hypotension

SOAP NOTES:

DAY ONE:

SUBJECTIVE: 

no fever spikes

                 

OBJECTIVE:

Pt is c/c/c

BP: 110/80 mm Hg

PR: 84 bpm

CVS - s1, s2 +

RS - BAE +

P/A - Soft, non-tender, Bowel sounds +

CNS - No FAD 

ASSESSMENT:

Viral Pyrexia with Thrombocytopenia- Dengue NS1

PLAN OF TREATMENT:

1) Plenty of oral fluids

2) IVF - 2.NS, 2.RL @ 75ml/hr

3) Inj. PANTOP 40 mg IV OD

4) Tab. PCM 650 mg PO TID

5) Temp charting 4th hrly and Tepid sponging

6) W/F Bleeding manifestations, postural hypotension

DAY TWO:

SUBJECTIVE: 

no fever spikes

                 

OBJECTIVE:

Pt is c/c/c

BP: supine: 110/80 mm Hg

       standing 1 min: 100/80 mm Hg

                       3 min: 110/80 mm Hg

PR: 74 bpm

CVS - s1, s2 +

RS - BAE +

P/A - Soft, non-tender, Bowel sounds +

CNS - No FAD 

ASSESSMENT:

Viral Pyrexia with Thrombocytopenia- Dengue NS1

PLAN OF TREATMENT:

1) Plenty of oral fluids

2) IVF - 2.NS, 2.RL @ 75ml/hr

3) Inj. PANTOP 40 mg IV OD

4) Tab. PCM 650 mg PO TID

5) Temp charting 4th hrly and Tepid sponging

6) W/F Bleeding manifestations, postural hypotension

COURSE IN THE HOSPITAL: 

35 yr old male admitted with complaints of fever since 5 days and loose stools 4 days back. He had 6 episodes of loose stools, which were , non-watery, not blood stained. Along with loose stools, patient also had complaints of low grade fever. The patient was managed conservatively. With improvement in overall condition and resolution of above mentioned symptoms pt was discharged and advised for follow up after 1 week