33 year old female

​Unit 6 admission 

Aug 13 2022


A 33 yr old female,works as a sister(labour room) in our hospital, came to casualty with 


COMPLAINTS OF 


1.Generalised body pains since 3 days

2. Fever since 3 days



HISTORY OF PRESENT ILLNESS 


1)BODY PAINS: 

started at 6 pm after going home which was sudden in onset, started initially in loin region (bilateral) followed by head ache diffuse and later generalised body pains which was dragging type and aggravated by walking 


2) fever 

Initiated after half an hr of bodypains, sudden In onset and continuos, relieved by taking medications and the fever developed again after 2 hours of taking medication which was associated with rigors and sweating. Sweating present after taking medication


PAST HISTORY 


N/K/C/O DM,HTN,ASTHMA,EPILEPSY, CVA,CAD


- Hysterotomy done ( APRIL 20 OF 2021)

- H/O Right side single renal calculi of 4mm present, consulted urologist in our hospital & took medications for 2 wks & drank adequate amount of water, & then the stone passed 


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 - 110/70mmHg

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:


Viral pyrexia with arthralgia secondary to ?viral


INVESTIGATIONS:


1631528060002440-0.png.jpg


ECG

1631528048262364-1.png.jpg


USG

1631528042245010-2.png.jpg

REVIEW USG

1631528030408420-3.png.jpg


X RAY

1631528025613810-4.png.jpg


1631528020857257-5.png.jpg


1631527998576380-6.png.jpg


ORTHO REFERRAL 

1631527989328367-7.png.jpg


SOAP NOTES


DAY 1

SUBJECTIVE 

1.Fever spikes present 


OBJECTIVE 

1.Temperature: 101°F

2.BP: 100/70MMHG

3.PR: 70BPM


ASSESSMENT 

1.Viral pyrexia 


PLAN OF CARE

1. IVF. NS AND RL AT 75 ML/HR

2. INJ. NEOMOL 100 ML NS IV/OD

3. INJ. TRAMADOL 1 AMP IN 100 ML NS IV/SOS

4. INJ PANTOP 40 MG IV/OD

5. INJ ZOFER 4 MG IV/SOS

6. TAB PCM 500 MG PO/TID 

7.TAB ULTRACET 1/2 QID

8. MONITOR VITALS 4TH HOURLY

9. TEMPERATURE CHARTING 


DAY 2

SUBJECTIVE:

1.Fever spikes present

2.Lower back ache radiating to groin


OBJECTIVE 

1.TEMPERATURE: 100°F

2.BP:100/70mmHg

3.PR:70bpm


ASSESSMENT 

1.Viral yrexia


PLAN OF CARE

1. IVF. NS AND RL AT 75 ML/HR

2. INJ. NEOMOL 100 ML NS IV/OD

3. INJ. TRAMADOL 1 AMP IN 100 ML NS IV/SOS

4. INJ PANTOP 40 MG IV/OD

5. INJ ZOFER 4 MG IV/SOS

6. TAB PCM 500 MG PO/TID

7. TAB ULTRACET 1/2 TAB QID 

8. MONITOR VIYALS 4TH HOURLY 

9. TEMPERATURE CHARTING


DAY 3

SUBJECTIVE 

1.Yesterday night fever with rigors present at 8 PM decreased at 9:30 pm

2.Again one fever spike was present at morning 4AM

3.C/O lower back pain radiating towards groin region

4.B/L UL small joint pains


OBJECTIVE 

Pt is C/C/C

1.TEMPERATURE: Afebrile 

2.BP: 110/70MMHG

3.PR: 74BPM

4.CVS: S1,S2 heard

5.CNS: No FND

6.RS:NVBS+

7.P/A:Soft,Non tender


ASSESSMENT 

1.Viral pyrexia with arthralgia secondary to ?viral


PLAN OF CARE 

1.IVF NS,RL @ 75ML/HR

2.INJ NEOMOL 100ML NS/OD

3.INJ TRAMODOL 1AMP IN 100ML NS IV/SOS

4.INJ PAN 40MG IV/PD

5.INJ ZOFER 4MG IV/SOS

6.TAB PCM 650MG PO/TID

7.TAB MYOSPAZ 8MG PO/BD

8.TAB TAXIM - O 200 MG PO/BD

9.TAB NAPROXEN 250MG PO/BD 

10.TEMPERATURE CHARTING 

11.MONITOR VITALS 4TH HRLY

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