A 45 YR OLD FEMALE WITH VIRAL PYREXIA

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Unit  6 admission
A 45 yr old female came with complaints of
-   fever since 1 week
- c/o SOB  since 1 week
- c/o decreased urine output, increased frequency
- h/o burning micturition +
HOPI : pt was apparently asymptomatic 1 week back , then she developed fever , which was continuous type , associated with chills and rigors
- it subsided on taking medication
- h/o SOB  ( grade2- grade 3)
Past history :
H/o chest pain 15 yrs back
And intermittent palpitations since 10-15 yrs
She is not a known  case of DM, HTN , asthma TB , epilepsy
Personal history :
Appetite : normal
Sleep : adequate
Diet : mixed
B&B  movements : regular

On  General examination :
Pt is C/C/C
No pallor, icterus  ,clubbing ,cyanosis, lymphadenopathy

Vitals :
BP- 120/80 mmHg
PR -76 BPM
Physical examination :
CVS :S1S2 + , no murmurs
P/A - soft , non tender
BS - +
RS :BAE+ , NVBS
CNS : NAD
Provisional diagnosis :viral pyrexia with thrombocytopenia

Treatment :
1) IVF -NS& RL & @100 ml/ HR
2) inj ceftriaxone 1 GM IV BD
3) inj pan 40 mg IV OD
4) inj neomol 1 GM IV SOS
If temp >101 F
5) Tab Dolo 650 mg po SOS

SOAP notes Day 2

Unit 6

AMC case 45 yr old female

S: sob reduced 

O :O/E 

Pt is C/C/C

Temp :98 .6  F

BP : 90/70 mmHg

PR - 82 BPM

CVS : S1S2 +

RS :BAE +

P/A : soft , non tender

CNS : no focal deficits

A : viral pyrexia with thrombocytopenia

        ? UTI

P :

1) IVF :NS,RL @ 100 ml/ hr

2) inj Ceftriaxone 1gm IV bd

3) inj pan 40 mg IV OD

4) inj neomol 1gm IV SOS

5)Tab. Dolo 650 po SOS

 6) monitoring vitals  BP/ PR/Temp charting

Soap notes Day 4

Unit 6

AMC case 45 yr old female

S: sob reduced , 

O :O/E 

Pt is C/C/C

Temp : 98.6f

BP : 130/90 mmHg

PR -90 BPM

CVS : S1S2 +

RS :BAE +

P/A : soft , non tender

CNS : no focal deficits

A : viral pyrexia with thrombocytopenia

        ? UTI

P :

1) IVF :NS,RL @ 100 ml/ hr

2) inj Ceftriaxone 1gm IV bd

3) inj pan 40 mg IV OD

4) inj neomol 1gm IV SOS

5)Tab. Dolo 650 po SOS

 6) monitoring vitals  BP/ PR/Temp charting

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