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A 50 year old female housewife by occupation came with C/O fever since 7 days
C/O headache since 7 days
C/O body pains since 7 days
HOPI-
Patient was apparently asymptomatic 7 days back then developed fever associated with chills and rigors ,subsided on taking medications
C/O headache -diffuse type,not associated with nausea ,vomiting since 7 days
C/O body pains since 7 days
Patient was taken to near by RMP and diagnosed with Dengue NS 1 antigen positive and treated conservatively.
HISTORY OF PAST ILLNESS:
No similar complaints in the past
Not a K/C/O DM/ TB/ BA / EPILEPSY.
K/c/o Htn since 10 years on amlodipine and atenolol
General examination -
Patient is consious, coherent, co-operative.
No pallor , icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 80 BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 98% AT RA
GRBS - 99 mg/dl
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
Invesigations-
On 13/4/22
Hb-11.7gm/dl
Tlc-1800cells/cumm
N/L/E/M-47/48/0/5
Plt-85,000lakhs/cu.mm
BGT-A +
RBS-202mg/dl
Blood Urea-20mg/dl
UA-4mg%
14/04/22
Hb-12.5
Tlc -1500cells/cumm
N/L/E/M47/48/0/5
PCV -35.9
Plt-60,000
Treatment-
1.IVF -NS,RL
2.INJ.PANTOP 40 MG/IV/OD
3.INJ ZOFER 4MG/IV/BD
4.INJ OPTINEURON 1 AMP IN 100ML NS
5.INJ.NEOMOL 100 ML( IF TEMP >101.1F)
6.TAB.PCM 500MG/PO/SOS
7.MONITOR VITALS HRLY
8.FEVER CHARTING 4TH HRLY
9.CHECK FOR BLEEDING
10.PCV AND BUN -DAILY
ENT referral-
3rd Unit ICU admission 14/4/2022
* SOAP NOTES Day 1
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
No pallor , icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 80 BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 98% AT RA
GRBS - 99 mg/dl
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
A-Fever with thrombocytopenia with NS1 positive
P-1.IVF -NS,RL
2.INJ.PANTOP 40 MG/IV/OD
3.INJ ZOFER 4MG/IV/BD
4.INJ OPTINEURON 1 AMP IN 100ML NS
5.INJ.NEOMOL 100 ML( IF TEMP >101.1F)
6.TAB.PCM 500MG/PO/SOS
7.MONITOR VITALS HRLY
8.FEVER CHARTING 4TH HRLY
9.CHECK FOR BLEEDING
10.PCV AND BUN -DAILY
3rd Unit ICU admission 15/4/2022
* SOAP NOTES Day 2
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
No pallor , icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate -64 BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG supine 100/80mmhg standing
SPo2 - 98% AT RA
GRBS - 99 mg/dl
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
A-Fever with thrombocytopenia with NS1 antigen positive
P-1.IVF -NS,RL
2.INJ.PANTOP 40 MG/IV/OD
3.INJ ZOFER 4MG/IV/BD
4.INJ OPTINEURON 1 AMP IN 100ML NS
5.INJ.NEOMOL 100 ML( IF TEMP >101.1F)
6.TAB.PCM 500MG/PO/SOS
7 .TAB VERTIN 16MG PO/TID
8.MONITOR VITALS HRLY
9.FEVER CHARTING 4TH HRLY
10.CHECK FOR BLEEDING
11.PCV AND BUN -DAILY
12 VALSALVA MANOEUVRE TID
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