viral pyrexia

A 47year old female patient came with c/o fever since 14 days 

She was apparently assymptomatic 15 days back then she developed 

swelling at the right parotid region ,the next day she developed fever which is low grade and subsided on taking medication , associated with chills,bodypains,headache,redness and watering from eyes 

She c/o  6-7episodes of loose stools 2 days back.  

No c/o nausea,vomitings,rashes.

They went to local hospital and stayed in hospital for 4days, fever subsided on taking medication but was recurring later,  

They came to our casualty with c/o fever and was given conservative treatment and patient went home.Later they went to hospital in nalgonda and stayed there and took treatment for 1 day and was referred here for further management

PAST HISTORY

NOT K/C/O DM,HTN,ASTHMA,TB,EPILEPSY 

PERSONAL HISTORY

Takes mixed diet

Appetite - decreased

Bowel AND Bladder movements- REGULAR

OCCASIONAL TODDY DRINKER

GENERAL EXAMINATION

NO PALLOR, ICTERUS ,CYANOSIS, CLUBBING, LYMPEDENOPATHY, PEDAL EDEMA

Moderately built and nourished

VITALS

TEMP-100.7°F

RR- 14 CPM

BP -100/60 MMHG 

Pr-89 bpm

SPO2- AT ROOM AIR 98%

SYSTEMIC EXAMINATION 

CVS - S1,S2 +

RS - BAE +, NVBS+

CNS - NO FOCAL NEUROLOGICAL DEFICITS

P/A - SOFT , NONTENDER, BOWEL SOUNDS +

INVESTIGATIONS

NS1- negative 

PROVISNAL DIAGNOSIS 

VIRAL PYREXIA WITH THROMBOCYTOPENIA

SOAP NOTES DAY 1

SUBJECTIVE-

Abdominal tenderness present in right hypochondrium,rt iliac fossa,rt lumbar region,heachche 

OBJECTIVE : patient is C/C/C

Temp : 102 F

BP- 90/60 mm Hg

PR- 68 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness present in RT hypochondrium 

Respiratory System- BAE +

ASSESSMENT 

Viral pyrexia with thrombocytopenia

PLAN OF CARE 

IVF NS RL@ 100 ML /HR

Inj.pan 40 mg iv OD bbf

Inj neomol 1gm iv sos

Tab dolo 649 mg po TID

W/f bleeding manifestations

Check for postural drop 

Inform sos

Soap notes day 2

SUBJECTIVE-

Abdominal tenderness decreased than uesterheachche 

OBJECTIVE : patient is C/C/C

Temp : 100.3° F

BP- 100/60 mm Hg

PR- 68 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness present in RT hypochondrium 

Respiratory System- BAE +,b/l inspiratory crepts + in ISA,IAA

ASSESSMENT 

Viral pyrexia with polyarthralgia

?clinical malaria

PLAN OF CARE 

IVF NS RL@ 100 ML /HR

Inj.pan 40 mg iv OD bbf

Inj neomol 1gm iv sos

Tab dolo 650 mg po TID

Inj.augmentin 1.2 gm bd 

Tab.doxycyline 100 mg po bd 

Grbs charting 6th hourly 

W/f bleeding manifestations

Check for postural drop 

Inform sos