A 45 year old female came to the OPD with the C/O Fever since 3 days
HOPI:
Pateiny came with c/o fever since 10 days
Generalised body pains since 10 days
Pain abdomen since 5 days
History of presenting illness:
Patient was apparently normal ten days back then she developed fever, low grade associated with chills and rigors not associated with cough, no burning micturiation, no vomitings, no loose stools. Fever subsided after medication 5 days back
Then since 5 days patient developed pain abdomen around umbilicus and epigastrium, non radiating associated with SOB grade 3 and 4, not associated with nausea and vomiting, loss of appetite
History of past illness:
Not a K/C/O HTN/DM/TB/Epilepsy/Asthma/CAD/CVA
Patient was hysterectomised 15 years ago
Family history - Not Significant
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- 120 bpm
BP- 90/60 mmHg
RR- 40 cpm
SpO2- 97% at RA
Fever chart:
Systemic Examination:
CVS- S1S2 heard, no murmurs
RS- BAE+ , B/L IAA, IMA crepts
CNS- NAD
P/A- Soft, Non-tender
Provisional diagnosis:
Viral Pyrexia with Thrombocytopenia, viral pneumonia, sepsis with MODS.
Investigations on admission:
Cue:
Albumin +
Ec : 2 to 3
Pc : 3 to 4
BS : negative
BP: negative
Sugar : negative
Blood cells and casts : negative
Blood urea: 90
Serum creatinine: 1.1
Na+ : 139
K+ : 4.8
Cl- : 95
LFT:
TB: 7.01
DB: 3.10
AST: 111
ALT: 75
ALP: 403
TP: 6.3
ALB: 2.0
ABG:
PH: 7.37
PCO2 : 53.3
PO2 : 38.1
HCO3- :30.3
ST. HCO3- : 26.7
MP: negative
HIV : Negative
HBSAG : negative
HCV : negative
RAPID DENGUE : negative
RTPCR : negative
Ecg:
2d echo:
usg:
Xray:
Ecg on 18/12/21
Review usg:
Investigations on 19/12/21
Hb: 9.3
Tlc: 20,800
Plt. Count : 3.73
Serum total bilirubin: 9.92
Direct bilirubin: 3.21
Serum creatinine : 0.7
Xray
Plan of treatment
1. Ivf NS/RL/DNS continuous at 100ml/hr
2. Inj. PAN 40mg IV BD
3. inj. ZOFER 4mg IV/SOS
4. Inj. NEOMOL 1gm IV/SOS
5. Inj. PIPTAZ 4.5 gm IV TID
6. Tab. PCM 650 mg PO/ SOS
7. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD
8 Tab. TUSQ 1 tab PO BD
9. SYP. ASCORYL-LS 10ml PO TID
10. NEB. IPRAVENT 6th hourly
NEB. BUDECORT 12th hourly
11. BP/PR/TEMP monitoring 4th hourly
12. GRBS charting 12th hourly.
13. Intermittent CPAP if not maintaining on O2
14. Syp. LACTULOSE 10 ml PO TID
