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A 42 y /F came to the casualty with complaints of fever , nausea , constipation , generalised weakness since 7days ; burning micturition since 1day
HOPI-
Patient was apparently asymptomatic 1week back , intermittent not associated with chills , rigors , associated with generalised weakness . Patient not able to get up from bed associated with nausea , constipation , passing flatus .
No c/o loose stools and vomitings.
C/o burning micturition since 1day .
Dry cough since 1day
No c/o sputum , SOB , bleeding manifestations.
Past history-
Not a k/c/o DM , HTN ,TB, Asthma ,CAD .
Personal history -
Diet - veg
Appetite - Decreased
Sleep - Adequate
Bowel & bladder movements - regular
Rashes and itching on eating non veg .
No addictions .
Family history - not significant.
On Examination -
Patient is c/c/c
Temp - 99°F
BP -120/80 mmHg
PR - 89bpm
RR -18cpm
GRBS - 112mg%
CVS - S1 S2 +ve
RS - BAE +ve
P/A - soft, NT,BAE +ve
Provisional diagnosis -Fever under evaluation
Investigations-
Treatment -
IVF -NS,RL,DNS @75ML)HR
INJ PANTOP 40MG IV OD
INJ ZOFER 4MG IV SOS
INJ OPTINEURON 1AMP IN 100ML NS IV OD
INJ NEOMOL 1GM IV SOS (IF TEMP >101°F)
TAB DOLO 650 MG PO SOS
SYP LACTULOSE 10ML PO H/S
SOAP NOTES
Day 1
S- one fever spike+ yesterday , decreased appetite , giddiness + , neck pains + , c/o burning micturition .
O-
Patient is c/c/c
Temp - 99°F
BP -110/90 mmHg
PR - 93bpm
RR -21cpm
GRBS - 112mg%
SpO2 -98%@RA
CVS - S1 S2 +ve
RS - BAE +ve
P/A - soft, NT,BAE +ve
A-
Fever under evaluation , ?UTI
IVF -NS,RL,DNS @75ML)HR
INJ OPTINEURON 1AMP IN 100ML NS IV OD
INJ NEOMOL 1GM IV SOS (IF TEMP >101°F)
INJ PANTOP 40MG IV OD
INJ ZOFER 4MG IV SOS
TAB DOLO 650 MG PO SOS
SYP LACTULOSE 15ml PO/BD
Day 2
S- decreased appetite , giddiness + , neck pains + , no fever spikes yesterday , decreased burning micturition .
O-
Patient is c/c/c
Temp - 99°F
BP -130/90 mmHg
PR - 88bpm
RR -20cpm
GRBS - 132mg%
SpO2 -98%@RA
I/O - 2000/1100
CVS - S1 S2 +ve
RS - BAE +ve
P/A - soft, NT,BAE +ve
A-
Fever under evaluation , ?UTI
P-
INJ OPTINEURON 1AMP IN 100ML NS IV OD
INJ NEOMOL 1GM IV SOS (IF TEMP >101°F)
TAB PANTOP 40MG IV OD
TAB ZOFER 4MG IV SOS
TAB DOLO 650 MG PO SOS
SYP LACTULOSE 10ML PO H/S
PLENTY OF ORAL FLUIDS
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