20/M Pain abdomen and fever

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AMC bed 8

 

20year old male came with c/o fever since 4 days and pain abdomen since 1 day 

Pt was apparently asymptomatic 4days back then had fever for 4 days, intermittent, high grade fever, associated with chills and rigors.

Pain abdomen in epigastric region, non radiating throbbing type of pain associated with loss of appetite, not associated with nausea, vomitings, loose stools, constipation, Malena, 

Vomitings 2 episodes, non bilious, non projectile and food as content, watery stools (4-5 episodes), no mucous/blood/dark coloured stools (subsided now)

No h/o Malena, petechiae, hematuria, giddiness, sweating, headache, palpitations, SOB

Pt is n/k/c/o DM, HTN, Epilepsy, CAD, CVA

Personal History:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

No addictions

General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp.-100 F

PR- 91 bpm

BP- 110/70 mmHg

RR- 17 cpm

SpO2- 99% at RA

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+ , NVBS+

CNS- NAD

P/A- Soft, mild tenderness in epigastric region

Investigations- 

24/12/21

SOAP notes

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -97.9 degree f

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 70 bpm

Rr- 15 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

25/12/2021

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -97.9 degree f

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 70 bpm

Rr- 15 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

26/12/21

SOAP 26/12/21

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -Afebrile

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 68 bpm

Rr- 14 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

Provisional diagnosis- Viral Pyrexia with Thrombocytopenia

Treatment-

IVF- RL, NS @75ML/HR

Inj. PANTOP 40mg IV/OD

Inj. ZOFER 4mg IV/SOS

Inj. NEOMOL 100ml (IV/SOS if temp >100f)

T. PCM 500mg PO/TID

I/O charting

Temperature charting

W/f for bleeding manifestations and postural hypotension