Viral pyrexia with thrombocytopenia (NS1 +)

A  25yr old female came to OPD with c/c/o 
fever since 4 days,
Abdomipainal pain, Vomitings, generalized weakness since 4 days 
Decreased appetite day since 1 day

Fever -Low grade, Intermittent associated with  chills & rigor, generalized weakness, decreased appetite, Abdominal pain, nausea, vomitings.
Vomitings-3 to 4 episodes/day, non bilious, non projectile food, water as content, no blood/mucous in stools
Pain- Dragging type, localised to epigastric & hypochondrial region 

Not a k/c/o DM, HTN, Asthma,TB, CAD
Past surgeries-
Family planning 8 years back
Personal History-
Single, Non vegetarian
Appetite-Decreased
B and B movements- Regular
No known allergies
On examination : 
Pt is c/c/c
Moderately built and nourished
No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema

Vitals:
Afebrile
PR: 102 bpm, regular
RR: 20 cpm
BP: 100/70mmHg-supine
Standing-80/70 mmhg
SPO2:
AT ROOM AIR-99%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp: BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness +,
 bowel sounds heard
Cns: No focal deficit
Power-(5/5. 5/5)
Tone-(normal. Normal)

Provisional Diagnosis-
Viral pyrexia with thrombocytopenia with serositis
Ns1 positive-outside report

Plan of care-
1.IVF 500ml NS, RL 100ml/hr
2.Inj.Pantop 40mg IV/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 1 gm IV/sos (If temp more than 101 degree Fahrenheit)
5.Tab.pcm 650mg po/tid
6.syp.mucaine gel 15ml-15ml-15ml
7.I/O charting
8.Temp charting
9.W/F bleeding manifestation and postural hypotension
10.Grbs-12th hrly









SOAP NOTES DAY 1
Subjective- No fever spikes.                                          
Objective-
Vitals:
Afebrile
PR: 102 bpm, regular
RR: 20 cpm
BP: 100/70mmHg-supine
Standing-80/70 mmhg
SPO2:
AT ROOM AIR-99%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp: BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness +,
 bowel sounds heard
Cns: No focal deficit
Power-(5/5. 5/5)
Tone-(normal. Normal)
Assessment-
Viral pyrexia with thrombocytopenia with serositis
Ns1 positive-outside report

Plan of care-
1.IVF 500ml NS, RL 100ml/hr
2.Inj.Pantop 40mg IV/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 1 gm IV/sos (If temp more than 101 degree Fahrenheit)
5.Tab.pcm 650mg po/tid
6.syp.mucaine gel 15ml-15ml-15ml
7.I/O charting
8.Temp charting
9.W/F bleeding manifestation and postural hypotension
10.Grbs-12th hrly

SOAP NOTES DAY 2
Subjective- No fever spikes.                                          
Objective-
Vitals:
Afebrile
PR: 98 bpm, regular
RR: 20 cpm
BP: 90/60mmHg-supine
Standing-90/60 mmhg
SPO2:
AT ROOM AIR-99%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp: BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness +,
 bowel sounds heard
Cns: No focal deficit
Power-(5/5. 5/5)
Tone-(normal. Normal)
Assessment-
Viral pyrexia with thrombocytopenia with serositis
Ns1 positive-outside report

Plan of care-
1.IVF 500ml NS, RL 100ml/hr
2.Inj.Pantop 40mg IV/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 1 gm IV/sos (If temp more than 101 degree Fahrenheit)
5.Tab.pcm 650mg po/tid
6.syp.mucaine gel 15ml-15ml-15ml
7.I/O charting
8.Temp charting
9.W/F bleeding manifestation and postural hypotension
10.Grbs-12th hrly


SOAP NOTES DAY 3
Subjective- No fever spikes.                                          
Objective-
Vitals:
Afebrile
PR: 95 bpm, regular
RR: 21 cpm
BP: 110/80mmHg-supine
Standing-100/70 mmhg
SPO2:
AT ROOM AIR-99%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp: BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness +,
 bowel sounds heard
Cns: No focal deficit
Power-(5/5. 5/5)
Tone-(normal. Normal)
Assessment-
Viral pyrexia with thrombocytopenia with serositis
Ns1 positive-outside report

Plan of care-
1.IVF 500ml NS, RL 100ml/hr
2.Inj.Pantop 40mg IV/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 1 gm IV/sos (If temp more than 101 degree Fahrenheit)
5.Tab.pcm 650mg po/tid
6.syp.mucaine gel 15ml-15ml-15ml
7.I/O charting
8.Temp charting
9.W/F bleeding manifestation and postural hypotension
10.Grbs-12th hrly





SOAP NOTES DAY 4
Subjective- No fever spikes.                                          
Objective-
Vitals:
Afebrile
PR: 95 bpm, regular
RR: 21 cpm
BP: 120/80mmHg-supine
Standing-120/80 mmhg
SPO2:
AT ROOM AIR-99%
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp: BAE+
Nvbs heard
Position of trachea- central
P/A: soft, tenderness +,
 bowel sounds heard
Cns: No focal deficit
Power-(5/5. 5/5)
Tone-(normal. Normal)
Assessment-
Viral pyrexia with thrombocytopenia with serositis
Ns1 positive-outside report

Plan of care-
1.Plenty of oral fluids 
2.Tab.Pantop 40mg PO/OD
3. TAB. ZINCOVIT PO/OD 
4. TAB. MVT PO/OD 
5.Tab.pcm 650mg po/tid
6.syp.mucaine gel 15ml-15ml-15ml

Discharge summary
Patient came to hospital with platelets count of 82,000, treatment given conservatively and on day three platelet count was improvised to 1.1 lakhs 
Planning for discharge 
Advice at discharge
1. PLENTY OF ORAL FLUIDS
2. TAB. PCM 650MG PO/SOS
3. TAB. ZINCOVIT PO/OD X 5DAYS
4. TAB. MVT PO/OD X 5DAYS
5. TAB. PANTOP 40MG PO/OD X 5DAYS
6. SYP. MUCAINE GEL(10ML) PO/TID

Review in GM OPD after 1 week /in case of sos


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