UNIT 3 ADMISSION

36 M came with the c/o decreasing platelets. 

Bank worker for Nalgonda, had a h/o fever with chills on Friday which resolved on taking mediciation after he was hospitalised on Monday, until yesterday evening. 

He had no h/o SOB, Vomitings, Blood in stools. 

On serial observation of his blood count, there was a significant decrease from 1.6 L (Saturday) to 26000 (yesterday afternoon). 

No h/o any surface / visceral bleeding manifestations. 

Since yesterday, his wife gives history of abdominal distension. Patient complains of SOB after taking food and fluids. 

Patient gives history of ?greenish-dark coloured stools. 

Serial Platelet Count since Saturday

Saturday - 1.6L

Monday - 99k 

Tues - 30k

Wednesday (Afternoon) - 26k

No past medical history. 

Appetite - Normal

Diet - mixed 

Sleep - Normal now, but could not sleep in the first 4 days of fever. So, on monday was administered ?sleeping pills (as per his wife) 

Bowel and Bladder - Regular and passed greenish-dark stools 

General Examination - 

NO pallor/ Icyerus/ Cyanosis/ lymphadenopathy/ Clubbing

Vitals at Presentation 

Temp Afebrile

BP 110/80

PR 75 / min

RR 15 / min

GRBS 121

GCS 15/15 

Spo2 98% on RA 

Resp - BAE + , NVBS 

CVS - S1 S2 heard 

Per Abd - soft, non tender 

CNS - NFND 

Provisional Diagnosis - ? Viral Pyrexia with Thrombocytopenia 

Examintion Day 1 @ 8 A.M 

Subjective - 

1. Abdominal Distension since yesterday

2. Reddish Spots on his chest

3. Mild SOB on consuming food and liquids 

Objective - 

BP 110/80 (All same in supine, standing for 2 minute and 3 minutes) 

PR 60 

Temp - 99.6 

Platelets - 40,000

CVS - S1 S2 Heard 

Resp - BAE + , NVBS 

CNS - NFND 

P/A - Diffuse Tenderness + , Fluid Thrill +, Bowel sounds + 

Day 3

SOAP NOTES 

SUBJECTIVE : No fever spikes 

OBJECTIVE : 

BP - 110/70 MM OF HG(SUPINE) , 100/70 (Standing 1 min and 3 min)

PR 80 BPM

Temp - 98.6 

CVS - S1 S2 Heard 

Rsp - BAE + , NVBS 

CNS - NFND 

PA - Soft, non tender 

ASSESSMENT : 

VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS 1 NON REACTIVE) with Platelet count 41,000

Plan : 

1. IVF 1 UNIT NS, RK @ 100 ML/HR

2. TAB. DOLO 650 MG /PO/TID

3. INJ NEOMOL 1 GM IV/SOS IF TEMP >101 F

4. TEMP CHARTING 2 HRLY AMD TEPID SPONGING

5. VITALS MONITORING 5 HRLY

6. INJ PAN 40 MG/IV/OD

7. TAB DOXY 100 MG /IV /OD

8. ZYTE GEL 

9. WATCH FOR BLEEDING MANIFESTATIONS AND POSTURAL HYPOTENSION