36 yr old female with fever
A VISHAL
1701006001
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Our 36 yr old female patient came to the opd with chief complaints of
Fever since 5 days.
Generalised weakness & headache since 5 days.
HOPI:-
Patient was Apparently asymptomatic 5 days back then she developed fever which is high grade , intermittent,relieved on taking medication associated with generalised weakness & body pains ,Headache which is diffuse since 5 days.
H/o Dry cough since 5 days , cold 3 days back .
H/o throat pain since 3 days.
H/ o pain abdomen which is right sided since today
H/o black coloured stools since yesterday.
H/o nausea.
No h/o vomiting, loose stools.
No h/o bleeding gums & red colured urine.
PAST HISTORY:-
Not a k/c/o HTN, DM, Epilepsy, thyroid,CAD.
GENERAL EXAMINATION:-
Patient was conscious, coherent, cooperative,well oriented to time place and person.
Moderately built & moderately nourished.
No pallor,Icterus,cyanosis, lymphadenopathy, clubbing.
Temp- 99.6 f
BP- 110/80 mmhg
PR- 86 bpm
RR- 22 cpm
Spo2- 98%
CVS- S1 S2 +
CNS- NAD
R/S - BAE +
P/A - soft,nontender .
Tenderness at the Right hypochondrium is elicited.
Investigations:-
22/09/22:-
ABG:-
HEMOGRAM(9:00am)
ABG:-
CHEST XRAY:-
LIPID PROFILE:-
HEMOGRAM:-
PROVISIONAL DIAGNOSIS:-
VIRAL PYREXIA WITH THROMBOCYTOPENIA WITH VIRAL HEPATITIS POLYSEROSITIS, WITH BILATERAL PLEURAL EFFUSION AND PULMONARY EDEMA, MILD ARDS.
TREATMENT:-
1) IV fluids NS @100 ml/hr.
2) TAB.DOLO 650 mg po/TID
3) INJ.ZOFER 4 mg IV/TID
4) INJ.PAN 4 mg IV /OD.
5) INJ.NEOMOL 1gm IV/ SOS.
23/9/22 at 8:00 am
Day 1:-
S: complaints of vomitings, abdominal pain, loose stools,
O: on examination
Patient is conscious, coherent, cooperative.
Temp-98. 3F
PR-80 bpm
RR-22 cpm
BP-100/80mmhg
Cvs - s1 s2+
R/S- BAE+
CNS- NAD
P/A - soft, tenderness elicited in right hypochondrium
A: viral pyrexia with thrombocytopenia
P: plan of treatment
1) IV fluids NS @100 ml/hr.
2) TAB.DOLO 650 mg po/TID
3) INJ.ZOFER 4 mg IV/TID
4) INJ.PAN 4 mg IV /OD.
5) INJ.NEOMOL 1gm IV/ SOS.
24/9/22 at 8:00 am
Day 2:-
S: complaints of abdominal pain, 3episodes of vomiting yesterday, swelling of right hand at cannula site
O: on examination
Patient is conscious, coherent, cooperative.
Temp-97.4F
PR-110 bpm
RR-24 cpm
BP-120/70 mmhg - supine
110/60mmhg- standing
Cvs - s1 s2+
R/S- BAE+
CNS- NAD
P/A - soft, tenderness elicited in right hypochondrium
A: viral pyrexia with thrombocytopenia with viral hepatitis with polyserositis.
P: plan of treatment
1) IV fluids NS @100 ml/hr.
2) TAB.DOLO 650 mg po/TID
3) INJ.ZOFER 4 mg IV/TID
4) INJ.PAN 4 mg IV /OD.
5) INJ.NEOMOL 1gm IV/ SOS.(if temp >101 f)
6) INJ METACHLOPROMIDE 5mg/iv/sos
7) INJ TRAMADOL 1amp in 100ml NS/IV/SOS
8) TAB ULTRACET 1/2 tab PO/QID
9) OINT THROMBOPHOB for L/A
10) plenty of oral fluids with ORS
25/9/22 at 8:00 am
Day 3:-
S: complaints of abdominal pain, nausea, SOB
Stools not passed.
O: on examination
Patient is conscious, coherent, cooperative.
Temp-97.4F
PR-110 bpm
RR-24 cpm
BP-120/80 mmhg - supine
100/60mmhg- standing
Spo2:- 95% on 4 Litres of o2
Cvs - s1 s2+
R/S- BAE+
CNS- NAD
P/A - soft, tenderness elicited in right hypochondrium
A: viral pyrexia with thrombocytopenia with viral hepatitis with polyserositis With bilateral pleural effusions with pulmonary edema.
P: plan of treatment
1) IV fluids NS @100 ml/hr.
2) TAB.DOLO 650 mg po/TID
3) INJ.ZOFER 4 mg IV/TID
4) INJ.PAN 4 mg IV /OD.
5) INJ.NEOMOL 1gm IV/ SOS.(if temp >101 f)
6) INJ METACHLOPROMIDE 5mg/iv/sos
7) INJ TRAMADOL 1amp in 100ml NS/IV/SOS
8) TAB ULTRACET 1/2 tab PO/QID
9) OINT THROMBOPHOB for L/A
10) plenty of oral fluids with ORS
26/9/22 at 8:00 am
Day 4:-
S: complaints of nausea, SOB
Stools not passed, cough, headache
O: on examination
Patient is conscious, coherent, cooperative.
Temp-98.3 F
PR-84 bpm
RR-22cpm
BP-110/70 mmhg - supine
100/60mmhg- standing
Spo2:- 96% on 4 ltrs of o2
85% on room air
Cvs - s1 s2+
R/S- BAE+
CNS- NAD
P/A - soft, non tender
A: viral pyrexia with thrombocytopenia with viral hepatitis with polyserositis With bilateral pleural effusions with pulmonary edema with mild ARDS.
P: plan of treatment
1) IV fluids NS 2 pints@75ml/hr.
2) TAB.DOLO 650 mg po/sos
3) INJ.ZOFER 4 mg IV/TID
4) INJ.PAN 4 mg IV /OD.
5) INJ.NEOMOL 1gm IV/ SOS.(if temp >101 f)
6) INJ METACHLOPROMIDE 5mg/iv/sos
7) INJ TRAMADOL 1amp in 100ml NS/IV/SOS
8) TAB NAPROXEN 250 mg PO /BD
9) OINT THROMBOPHOB for L/A
10) plenty of oral fluids with ORS
