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
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
