A 20 yr female house wife with fever and thrombocytopenia
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 HTN/ DM/ TB/ BA / EPILEPSY.
2015:Thyroidectomy 7 yrs ago due to diffuse thyroid swelling
Jan 2022 she is diagnosed with right breast fibroadenoma and lump was removed .
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 - 110/80MM 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
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
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 - 82BPM, REGULAR, NORMAL VOLUME
BP - 110/80MM OF HG
SPo2 - 98% AT RA
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
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
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 - 86BPM, REGULAR, NORMAL VOLUME
BP - 110/80MM OF HG
SPo2 - 98% AT RA
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
P-1.IVF -NS,RL@ 100ml/hr
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
Soap notes 3
SOAP NOTES Day 3
S- No fresh complaints
O- Patient is consious, coherent, co-operative.
No pallor , icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 88BPM, REGULAR, NORMAL VOLUME
BP - 110/80MM OF HG
SPo2 - 98% AT RA
SYSTEMIC EXAMINATION -
P/A : Non distended, soft, non tender. No guarding or rigidity.
CVS : S1 S2 heard
RS-BAE+
CNS- NAD
P-1.IVF -NS,RL@ 100ml/hr
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
