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A 33 YR OLD FEMALE

Unit 6 admission 

A 33 yr old female,works as a sister(labour room) in our hospital, came to casualty with 

COMPLAINTS OF 

1.Generalised body pains since 3 days
2. Fever since 3 days


HISTORY OF PRESENT ILLNESS 

1)BODY PAINS: 
started at 6 pm after going home which was sudden in onset, started initially in loin region (bilateral) followed by head ache diffuse and later generalised body pains which was dragging type and aggravated by walking 

2) fever 
Initiated after half an hr of bodypains, sudden In onset and continuos, relieved by taking medications and the fever developed again after 2 hours of taking medication which was associated with rigors and sweating. Sweating present after taking medication

PAST HISTORY 

N/K/C/O DM,HTN,ASTHMA,EPILEPSY, CVA,CAD

- Hysterotomy done ( APRIL 20 OF 2021)
- H/O Right side single renal calculi of 4mm present, consulted urologist in our hospital & took medications for 2 wks & drank adequate amount of water, & then the stone passed 

PERSONAL HISTORY 

Diet - Mixed
Appetite - normal
Sleep - Adequate 
Bowel & Bladder movements  - normal
Addictions - Absent 

GENERAL  EXAMINATION 
Pt is conscious, coherent and cooperative .moderately built & nourished 
1.No pallor
2.No icterus
3.No clubbing,cyanosis
4.No koilonychia
5.No lymphadenopathy 
6.No edema

VITALS :

1.Temperature - afebrile 
2. BP - 110/70mmHg
3. PR - 74bpm


PER ABDOMEN:

- No distended abdomen
- No abdominal tenderness
- No engorged veins
- Gaurding & rigidity absent

RESPIRATORY SYSTEM:
BAE+ 
NVBS 

CVS :
 S1S2 HEARD 
no thrills no murmurs

CNS
All superficial & deep reflexes are normal 
 
PROVISIONAL DIAGNOSIS:

Viral pyrexia with arthralgia secondary to ?viral

INVESTIGATIONS:

ECG

USG
REVIEW USG
X RAY



ORTHO REFERRAL 
SOAP NOTES

DAY 1
SUBJECTIVE 
1.Fever spikes present 

OBJECTIVE 
1.Temperature: 101°F
2.BP: 100/70MMHG
3.PR: 70BPM

ASSESSMENT 
1.Viral pyrexia 

PLAN OF CARE
1. IVF. NS AND RL AT 75 ML/HR
2. INJ. NEOMOL 100 ML NS IV/OD
3. INJ. TRAMADOL 1 AMP IN 100 ML NS IV/SOS
4. INJ PANTOP 40 MG IV/OD
5. INJ ZOFER 4 MG IV/SOS
6. TAB PCM 500 MG PO/TID 
7.TAB ULTRACET 1/2 QID
8. MONITOR VITALS 4TH HOURLY
9. TEMPERATURE CHARTING 

DAY 2
SUBJECTIVE:
1.Fever spikes present
2.Lower back ache radiating to groin

OBJECTIVE 
1.TEMPERATURE: 100°F
2.BP:100/70mmHg
3.PR:70bpm

ASSESSMENT 
1.Viral yrexia

PLAN OF CARE
1. IVF. NS AND RL AT 75 ML/HR
2. INJ. NEOMOL 100 ML NS IV/OD
3. INJ. TRAMADOL 1 AMP IN 100 ML NS IV/SOS
4. INJ PANTOP 40 MG IV/OD
5. INJ ZOFER 4 MG IV/SOS
6. TAB PCM 500 MG PO/TID
7. TAB ULTRACET 1/2 TAB QID 
8. MONITOR VIYALS 4TH HOURLY 
9. TEMPERATURE CHARTING

DAY 3
SUBJECTIVE 
1.Yesterday night fever with rigors present at 8 PM decreased at 9:30 pm
2.Again one fever spike was present at morning 4AM
3.C/O lower back pain radiating towards groin region
4.B/L UL small joint pains

OBJECTIVE 
Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 110/70MMHG
3.PR: 74BPM
4.CVS: S1,S2 heard
5.CNS: No FND
6.RS:NVBS+
7.P/A:Soft,Non tender

ASSESSMENT 
1.Viral pyrexia with arthralgia secondary to ?viral

PLAN OF CARE 
1.IVF NS,RL @ 75ML/HR
2.INJ NEOMOL 100ML NS/OD
3.INJ TRAMODOL 1AMP IN 100ML NS IV/SOS
4.INJ PAN 40MG IV/PD
5.INJ ZOFER 4MG IV/SOS
6.TAB PCM 650MG PO/TID
7.TAB MYOSPAZ 8MG PO/BD
8.TAB TAXIM - O 200 MG PO/BD
9.TAB NAPROXEN 250MG PO/BD 
10.TEMPERATURE CHARTING 
11.MONITOR VITALS 4TH HRLY

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