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A 45 YR OLD FEMALE

UNIT 6 ADMISSION 

A 45 old female came to casualty with 

COMPLAINTS OF 
1.Fever since 4 days
2.Vomitings since 4 days
3.Loose stools since 4 days

Patient was apparently asymptomatic 4 days back

1.FEVER
Was low grade,intermittent not associated with chills & rigors

2.VOMITINGS 
-5 to 6 episodes/day,non bilious non projectile,food/water as content 

3.LOOSE STOOLS 
-2 to 3/day,watery in consistency,no blood/mucous in stools associated with abdominal discomfort 

- pt had h/o intermittent high colored urine(she described as red)
-SOB intermittently since 1 month associated with orthopnea

PAST HISTORY 

Pt was apparently asymptomatic 3 yrs back,then pt had 
- Pain in B/L knee - 3 yrs causing unable to walk properly for which she used to take NSAIDS for severe pain 
- 2 MONTHS BACK:
She slipped from staircase,had fracture of Rt tibia & underwent surgery 1 month back in a hospital in nalgonda & also got diagnosed to be diabetic .since then GRBS : 150MG/dl 

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 - 100/70mmHg
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:

- Acute Gastroenteritis with DM 2
- ?Candidiasis of oral cavity with Rt tibia# - infected Rt ILMN tibia with loosening of implants 

INVESTIGATIONS 
19/9/21 LFT
19/9/21 BLOOD UREA 
19/9/22  SERUM ELECTROLYTES 
19/9/21   CUE
19/9/21  HEMOGRAM 

HBA1C
RBS
BLOOD UREA
21/9/21  SERUM CREATININE 
21/9/21  SERUM ELECTROLYTES 
21/9/21(12PM)
21/9/21(8AM)
CRP

X ray 

TREATMENT 
Day 1
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.VITALS & TEMPERATURE CHARTING 4TH HRLY
8.PHYSIOTHERAPY

Day 2
1.IVF NS,RL @ 100ML/HR
2.INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.VITALS & TEMPERATURE CHARTING 4TH HRLY
8.PHYSIOTHERAPY

DAY 3
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.TAB FLUCONAZOLE 150MG PO/STAT
8.CANDID MOUTH (L/A) PASTE
9.TAB OROFER- XT PO/BD
10.GRBS 70 PROFILE
11.VITALS & TEMPERATURE CHARTING 4TH HRLY 
12.PHYSIOTHERAPY 

DAY 4
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.INJ MONOCEF 1GM IV/BD
7.INJ CLOXANE 40MG S/C - OD
8.GRBS 70 PROFILE
9.TAB FLUCONAZOLE 150MG PO/STAT
10.CANDID MOUTH (L/A) PASTE
11.TAB OROFER- XT PO/BD
12.GRBS 70 PROFILE
13VITALS & TEMPERATURE CHARTING 4TH HRLY 
14.PHYSIOTHERAPY 

DAY 5
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.6.INJ MONOCEF 1GM IV/BD
7.INJ CLOXANE 40MG S/C - OD
8.GRBS 70 PROFILE
9.TAB FLUCONAZOLE 150MG PO/STAT
10.CANDID MOUTH (L/A) PASTE
11.TAB OROFER- XT PO/BD
12.GRBS 70 PROFILE
13.VITALS & TEMPERATURE CHARTING 4TH HRLY 
14.PHYSIOTHERAPY 

FEVER CHART 
SOAP NOTES 

DAY 1
WARD 
SUBJECTIVE 
-fever
- vomitings 
- loose stools

OBJECTIVE 

Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 100/80MMHG
3.PR: 70BPM
4.CVS: S1,S2 
5.RS:NVBS+
6.P/A : Soft,non tender 
7.CNS: No FND

ASSESSMENT 
1.Acute GE with DM2

PLAN OF CARE 
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.VITALS & TEMPERATURE CHARTING 4TH HRLY

Day 2
SOAP NOTES 

WARD 

SUBJECTIVE 
-1 episode of vomiting at afternoon 
- fever

OBJECTIVE 

Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 100/70MMHG
3.PR: 74BPM
4.CVS: S1,S2 
5.RS:NVBS+
6.P/A : Soft,non tender 
7.CNS: No FND

ASSESSMENT 
1.Acute GE with DM2

PLAN OF CARE 
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.VITALS & TEMPERATURE CHARTING 4TH HRLY

SOAP NOTES 

DAY 3
Ward

SUBJECTIVE 
-1 episode of vomiting 
- 1 fever spike was present 

OBJECTIVE 

Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 100/80MMHG
3.PR: 70BPM
4.CVS: S1,S2 
5.RS:NVBS+
6.P/A : Soft,non tender 
7.CNS: No FND

ASSESSMENT 
1.Acute GE with DM2

PLAN OF CARE 
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.VITALS & TEMPERATURE CHARTING 4TH HRLY

SOAP NOTES 

WARD 

DAY 4

SUBJECTIVE 
- 1 fever spike was present at morning 

OBJECTIVE 

Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 110/80MMHG
3.PR: 72BPM
4.CVS: S1,S2 
5.RS:NVBS+
6.P/A : Soft,non tender 
7.CNS: No FND

ASSESSMENT 
1.Acute GE with DM2

PLAN OF CARE 
1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5.INJ HAI ACC TO SLIDING SCALE
6.GRBS 70 PROFILE
7.TAB FLUCONAZOLE 150MG PO/STAT
8.CANDID MOUTH (L/A) PASTE
9.TAB OROFER- XT PO/BD
10.GRBS 70 PROFILE
11.VITALS & TEMPERATURE CHARTING 4TH HRLY
12.PHYSIOTHERAPY

SOAP NOTES 

AMC

DAY 5

SUBJECTIVE 

- fever was present from night to morning 4AM 
- 1 episode of vomiting present 

OBJECTIVE 

Pt is C/C/C
1.TEMPERATURE: Afebrile 
2.BP: 110/80MMHG
3.PR: 72BPM
4.CVS: S1,S2 
5.RS:NVBS+
6.P/A : Soft,non tender 
7.CNS: No FND

ASSESSMENT 

1.Acute GE with DM2
2.?Candidiasis of oral cavity with Rt tibia# - infected Rt ILMN tibia with loosening of implants 

PLAN OF CARE 

1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5. INJ NEOMOL 1gm IV/SOS( IF TEMP >101°F)
6.INJ MONOCEF 1gm IV/BD
7.INJ METROGYL 400MG IV/TID
8.INJ HAI ACC TO SLIDING SCALE
9.GRBS 70 PROFILE
10.TAB FLUCONAZOLE 150MG PO/STAT
11.CANDID MOUTH (L/A) PASTE
12.TAB OROFER- XT PO/BD
13.GRBS 70 PROFILE
14.VITALS & TEMPERATURE CHARTING 4TH HRLY
15.PHYSIOTHERAPY

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