40/F with high grade fever
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40 year old female with to casualty with complaints of
high grade fever since 5-6 days
C/o vomitings since yesterday
C/o loose stools since today.
History of presenting illness :
Patient was apparently asymptomatic 5-6 days then she developed fever , sudden high grade not a/w chills and rigors , intermittent, relieved temporarily on medication.
C/i vomiting since yesterday h/o 3-4 episodes , content good particles ,non bilious , non projectile , nausea present
C/o abdominal bloating since yesterday
C/o SOB since yesterday , releived on lying down,
No chestpain , palpitations PND orthopnea
C/o loose stools since today , watery consistency, 4-5 episodes ,small quantity, non blood stained , not associated with pain abdomen.
C/o epigastric pain since today , insidious onset , continuous , non radiating
Past history :
N/k/c/o HTN DM CVA CAD TB ATHMA
K/c/o Hypothyroidism since 10 years on tab. Thyronorm 100mcg /po/ od using irregularly since 15 days
Family history :
No similar complaints
Personal history :
Sleep : Normal
Diet : Mixed
Appetite : Normal
Bowel and Bladder Movements : Regular
Addictions : none
General examination :
Pt is c/c/c
No pallor , icterus , cyanosis, clubbing, lympadenopathy, edema
Vitals :
PR: 124bpm
RR: 18cpm
BP: 70 systolic ( palpatory)
GRBS : 183mg%
Systemic examination :
CVS : S1 s2 heard no murmurs
RS : BAE NVBS heard
P/A : epigastric tenderness present
No free fluid.
CNS : No FND
Investigations :
Ultrasound :
X-RAY CHEST :
Treatment :
IV FLUIDS NS & RL @100ML/HR
INJ.PIPTAZ (D6) 2.5GM IV /TID
(D5) TAB. AZITHROMYCIN 500MG PO/OD 8AM
T. THYRONORM 100MCG PO/OD
(8AM- 15MINS BEFORE FOOD)
INJ. DROTIN IM/SOS
INJ. PAN 40MG/IV/BD
INJ. ZOFER 4MG IV/BD
Fever chart :
Soap notes :
Soap notes
10/6/2023
AMC Cubicle
Dr. Zain (SR)
Dr. Pavan (PGY2)
Dr. Lohith (PGY1)
S:
- SOB resolving
- Pain abdomen resolving (hypochondrium)
- Did not pass stools
- No fever spikes
O:
Pt has conscious, coherent, cooperative.
BP: 110/70mmhg
PR: 82 bpm
RR: 16 cpm.
Spo2: 99%
CVS: S1 s2 heard , no murmurs RS: B/L air entry present NVBS +
Decreased air entry in lt. IMA
P/A: mild tenderness in right hypochondrium
A:
HYPOVOLEMIC SHOCK SEOCNDARY TO ACUTE GE (RESOLVED)
? COMMUNITY AQUIRED PNEUMONIA
WITH ? LEFT LOWER LOBE PNEUMONIA (BACTERUA US ATYPICAL)
WITH ACUTE CALCULUS CHOLECYSTITIS
WITH K/C/O HYPOTHYROIDISM
P:
IV FLUIDS NS & RL @100ML/HR
INJ.PIPTAZ (D6) 2.5GM IV /TID
(D5) TAB. AZITHROMYCIN 500MG PO/OD 8AM
T. THYRONORM 100MCG PO/OD
(8AM- 15MINS BEFORE FOOD)
INJ. DROTIN IM/SOS
INJ. PAN 40MG/IV/BD
INJ. ZOFER 4MG IV/BD
MONITOR VITALS 4TH HOURLY
Soap notes
11/6/2023
AMC Cubicle
Dr. Zain (SR)
Dr. Pavan (PGY2)
Dr. Lohith (PGY1)
S:
- SOB resolving
- Pain abdomen resolving (hypochondrium)
- Did not pass stools
- No fever spikes
O:
Pt has conscious, coherent, cooperative.
BP: 110/70mmhg
PR: 82 bpm
RR: 16 cpm.
Spo2: 99%
CVS: S1 s2 heard , no murmurs RS: B/L air entry present NVBS +
Decreased air entry in lt. IMA
P/A: mild tenderness in right hypochondrium
A:
HYPOVOLEMIC SHOCK SEOCNDARY TO ACUTE GE (RESOLVED)
? COMMUNITY AQUIRED PNEUMONIA
WITH ? LEFT LOWER LOBE PNEUMONIA (BACTERUA US ATYPICAL)
WITH ACUTE CALCULUS CHOLECYSTITIS
WITH K/C/O HYPOTHYROIDISM
P:
IV FLUIDS NS & RL @100ML/HR
INJ.PIPTAZ (D6) 2.5GM IV /TID
(D5) TAB. AZITHROMYCIN 500MG PO/OD 8AM
T. THYRONORM 100MCG PO/OD
(8AM- 15MINS BEFORE FOOD)
INJ. DROTIN IM/SOS
INJ. PAN 40MG/IV/BD
INJ. ZOFER 4MG IV/BD
MONITOR VITALS 4TH HOURLY
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