35 Y / F with Fever and neck pain under evaluation
Unit 1 admission
Ward
35 yr old female , daily wage labourer by occupation prese.ted to op with
c/o fever since 1 week ,
High grade , a/w chills and rigors with generalised weakness , nausea , burning micturition+
Head ache and neck pain
No cough , SOB
Not a k/c/o HTN , DM
O/E :
PR 99 bpm
BP 120/80 mmHg
RR 22 cpm
Temp 100 F
Grbs 121 mg/dl
Spo2 99% room air
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
Clinical images :
Investigations :
On 8/11/21
CUE :
Colour : pale yellow
Appearance : clear
Epi .cells : 2-3
Pus cells 2-3
Alb , sugar : Nil
Hemogram :
HB 10.3
TLC 8100
L 47
Plt 4.0 L
PCV 32 %
MCV 71.8
Mch 22.7
S electrolytes :
Na 135
K 4.6
Cl 95
S creat 0.7
LFT
TB 0.45
Db 0.16
Ast 27
Alt 40
Alp 282
TP 6.9
Alb 3.6
A/G 1.12
Blood urea 17
BGT O +
On 9/11/21
CXR :
X Ray C spine :
Provisional diagnosis :
FEVER UNDER EVALUATION
TREATMENT :
IVF NS RL 100 ml per hr
INJ pan 40 mg /iv/od
INJ neomol 100 ml if temp more than 101 F
Tab PCM 500 mg / po/ tid
INJ optineuron 1 ampule 100 ml. NS / iv / bd
SOAP notes :
Day 1
9/11/21
Fever chart :
S : No fever spikes
C/0 neck pain , generalised body pains
O : Pt is conscious ,coherent, cooperative
O/E :
PR 78 bpm
BP 100 /80 mmHg
RR 22 cpm
Temp 98.2 F
Spo2 99% room air
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
A : Fever under evaluation
P :
IVF NS RL 100 ml per hr
INJ pan 40 mg /iv/od
INJ neomol 100 ml if temp more than 101 F
Tab PCM 500 mg / po/ tid
INJ optineuron 1 ampule 100 ml. NS / iv / bd
SOAP NOTES
DAY 2
10/11/21
FEVER CHART :
S : No fever spikes
C/0 neck pain , generalised body pains
O : Pt is conscious ,coherent, cooperative
O/E :
PR 72 bpm
BP 100 /80 mmHg
RR 22 cpm
Temp 98.0 F
Spo2 99% room air
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Soft , non tender
Bowel sounds +
A : Fever under evaluation
P :
IVF NS RL 100 ml per hr
INJ pan 40 mg /iv/od
INJ neomol 100 ml if temp more than 101 F
Tab PCM 500 mg / po/ tid
INJ optineuron 1 ampule 100 ml. NS / iv / bd
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