VIRAL PYREXIA WITH THROMBOCYTOPENIA

45 year female came with chief complaints of fever since 3 days 
HISTORY OF PRRSENT ILLNESS :- 
patient was apparently asymptomatic 10 days before  she had fever which is mild degree of fever subsided with medication by a local rmp. after one week she developed fever again where the attenders brought here to the hospital  with chief complaints of. fever 
which is high grade fever , intermittent , aggrevating at night time , associated with  chills  and sweating at the duration of fever .
and pain at the both  eye brow region.
and pain of lower limbs which is dragging tyoe of pain and relieved when the fever subsided .
the patient also complains of  discomfort in the abdomen since 1 days .

PAST HISTORY 
K/C/O  htn since 6 months and she is on medication 
Not a k/c/0 dm, asthma , epilepsy 
PERSONAL HISTORY :- 
appetite : decreased 
Diet : vegeterian 
Sleep : adequate 
Bowel and bladder:  regular 
No addictions 
FAMILY HISTORY :- 
not significant 
ON EXAMINATION :- 
Patient is conscious ,coherent , coperative 
Vitals :- 
Temp afebrile 
Bp 120/80 mm hg 
Pr  78 BPM 
Spo2. 99   
SYSTEMIC EXAMINATION 
CVS : S1 S2 HEARD 
RS : BAE  present 
CNS : no neurological deficit 
P/A soft  tender  at epigastric region
INVESTIGATIONS :-
Usg 15/2//22
cheat x ray

16/2/22

17/2/22
Hemogram
HB 14
TLC 15;000
N/L/M/E/B:- 33/55/10/2/0
PLT 40;000

18/2/22
PLT 80;000

19/2/22

PLT. 1.15 LAKHS 


45 yr old female 
AMC bed 5 
S : patient is complaining of  generalised weakness and pain abdomen 
O: pt is c/c/c 
Afebrile 
Pr  84bpm
Bp 100/60 mm hg 
Rr 16 cpm
Spo2 : 98%
P /A : mild tendernesss present in epigastric region
CvS.  s1 S2 + 
CNS. NAD
R/S    BAE + 
A: viral pyrexia with thrombocytopenia 
P:
1.ivf ns and RL UO + 75 ML/HR 
2.INJ PANTOP 40 MG IV/bd 
3.inj Tramadol 1 amp in 100 ml ms IV/of 
4.inj .zofer 4 mg iv /sos 
5.inj buscopan 2 cciv/sos
6.tab pcm 500 mg po/tid

45 yr old female 
AMC bed 5 
S :  generalised weakness and pain abdomen  decreased compared to yesterday
O: pt is c/c/c 
Afebrile 
Pr  80bpm
Bp 100/70mm hg 
Rr 16 cpm
Spo2 : 98%
P /A : mild tendernesss present in epigastric region
CvS.  s1 S2 + 
CNS. NAD
R/S    BAE + 
A: viral pyrexia with thrombocytopenia 
P:
1.ivf ns and RL UO + 75 ML/HR 
2.INJ PANTOP 40 MG IV/bd 
3.inj Tramadol 1 amp in 100 ml ms IV/of 
4.inj .zofer 4 mg iv /sos 
5.inj buscopan 2 cciv/sos
6.tab pcm 500 mg po/tid

45 yr old female 
Ward case 
S :  generalised weakness and pain abdomen  decreased.no other fresh complaints 
O: pt is c/c/c 
Afebrile 
Pr  80bpm
Bp 110/80mm hg 
Rr 16 cpm
Spo2 : 98%
P /A : mild tendernesss present in epigastric region
CvS.  s1 S2 + 
CNS. NAD
R/S    BAE + 
A: viral pyrexia with thrombocytopenia 
P:
1.ivf ns and RL UO + 75 ML/HR 
2.INJ PANTOP 40 MG IV/bd 
3.inj Tramadol 1 amp in 100 ml ms IV/of 
4.inj .zofer 4 mg iv /sos 
5.inj buscopan 2 cciv/sos
6.tab pcm 500 mg po/tid

Soap notes 

45 yr old female 
Ward case 
S : pain abdomen subsided 
O: pt is c/c/c 
Afebrile 
Pr  80bpm
Bp 110/80mm hg 
Rr 16 cpm
Spo2 : 98%
P /A : soft , non tender 
CvS.  s1 S2 +
CNS. NAD
R/S    BAE + 
A: viral pyrexia with thrombocytopenia 
P:
1.plenty of oral fluids 
2.tab pantop 40 mg  po/od
3.tab pcm 500 mg po/sos
PLAN FOR DISCHARGE


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