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A CASE OF 30YR FEMALE

Unit 6 admission

A 30 yr old female, resident of  miryalguda & farmer by occupation. came to casualty with 

COMPLAINTS OF 

1. Fever since 3 days
2. Vomitings since 3 days
3. Head ache since 3 days
4. Legs pain since 3 days
5. Stomach pain since 3 days

HISTORY OF PRESENT ILLNESS:

1.FEVER :

- Low grade, intermittent associated with chills & rigors, increased during nights & relieved with medications 

2.VOMITINGS :
- 3 - 4 episodes/ day
- occurs after food intake,non projectile,non bilious, food as content

3.HEAD ACHE :
- Gradual onset,pricking type on both frontal region,increased after vomitings 

4.LEGS PAIN :
- Bilateral legs pain till hip,gradual onset,dragging type, associated & increased with fever spikes

5. STOMACH PAIN :
- Diffuse type, gradual onset & increased after vomitings

NEGATIVE HISTORY:

- no h/o loose stools,burning mictiration

PAST HISTORY:

- Got admitted in a local hospital near miryalguda 2 days back for fever complaints & shifted to our hospital for decreased platelet count
- Not a known case of DM,HTN,Epilepsy,Thyroid
- No similar complaints in past

FAMILY HISTORY:

- No significant family History 

PERSONAL HISTORY:

1.Diet - mixed
2.Appetite - normal
3.Sleep - Adequate 
4. Bowel & Bladder movements - normal
5. Addictions - Absent

DRUG & SURGICAL HISTORY:
Not significant 

GENERAL EXAMINATION:

Pt is consious,cooperative & coherent, 

No pallor 
No icterus 
No clubbing, cyanosis 
No koilonychia
No lymphadenopathy
No Edema 

VITALS :

1.Temperature : 99.4°F
2. BP : Supine - 110/80mmHg
      : Standing - 100/80mmHg
3. PR : 74 bpm
4. RR :20 cpm

SYSTEMIC EXAMINATION :

PER ABDOMEN:

- No distended abdomen
- abdominal tenderness - +ve
- No engorged veins
- Gaurding & rigidity present

RESPIRATORY SYSTEM:
BAE+ 
NVBS 

CVS :
 S1S2 HEARD 
no thrills no murmurs

CNS:
All superficial and deep reflexes are normal 

PROVISIONAL DIAGNOSIS:

Viral pyrexia with thrombocytopenia

INVESTIGATIONS:

HEMOGRAM:

2 DAYS BACK:
- TOTAL WBC COUNT: 7,500cells/cumm
- PLATELET COUNT: 35,000/cumm
- PCV: 34.4%

1 DAY BACK:
- TOTAL WBC COUNT: 6,600cells/cumm
- PLATELET COUNT: 50,000/cumm
- PCV: 32.7%

TODAY:
-TOTAL WBC COUNT: 7,400cells/cumm
- PLATELET COUNT: 70,000/cumm
- PCV: 34.4%

SEROLOGY- Negative 
RTPCR - Negative 

RBS: 

BGT :
CUE :
 
BLOOD UREA:

SERUM CREATININE:

SERUM  ELECTROLYTES:

ECG :
USG :

TREATMENT:
 
ON 28/8/21

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1

ON 29/8/21

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1

ON 30/8/21

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1

FEVER CHART:
SOAP NOTES:

ON 28/8/21

SUBJECTIVE 
1.fever
2.Vomitings 
3.leg pain
4.stomach pain
5. Head ache

OBJECTIVE 
1.Temperature - Afebrile 
2. BP - Supine : 100/70mmHg
            Standing: 100/70mmHg
3.PR - 96bpm

ASSESSMENT 
1.fever with thrombocytopenia 

PLAN OF CARE

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1
6.WATCH FOR BLEEDING MANIFESTATIONS 
7. POSTURAL BP MONITORING 

ON 29/8/21

SUBJECTIVE 
1.No fresh complaints 

OBJECTIVE 
1.Temperature - Afebrile 
2. BP - Supine : 100/70mmHg
            Standing: 100/80mmHg
3.PR - 86bpm

ASSESSMENT 
1.fever with thrombocytopenia 

PLAN OF CARE

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1
6.WATCH FOR BLEEDING MANIFESTATIONS 
7. POSTURAL BP MONITORING 

ON 30/8/21

SUBJECTIVE 
1.No fever complaints 
2.Headache

OBJECTIVE 
1.Temperature - Afebrile 
2. BP - Supine : 110/70mmHg
            Standing: 100/70mmHg
3.PR - 80bpm

ASSESSMENT 
1.fever with thrombocytopenia 

PLAN OF CARE

1.IVF NS,RL @ 100ml/hr
2.TAB DOLO 650 MG/PO/TID
             1-------1-----1
3. INJ NEOMOL 100 ML/IV/SOS if temp >101°F
4. INJ ZOFER 4MG/IV/BD
         1-------1------1
5. INJ PANTOP 40MG/IV/OD
          1-------1------1
6.WATCH FOR BLEEDING MANIFESTATIONS 
7. POSTURAL BP MONITORING 

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