A 60 year old Female

A 60 year old female came to opd with 
C/O fever since 2 days 
C/O head ache since today evening 

Hopi:
Patient was apparently alright 2 days then she developed fever which is sudden in onset,low grade,continous releived with medication,no nausea ,no vomitings,fever not associated with chills and rigors,no cough,no cold,no shortness of breath,no burning micturition,c/o head ache since today morning frontal head ache,no photophobia,no phonophobia,no retroorbital pain.

Past illness:
K/c/o HTN since 6 years 
N/k/c/o Dm,Asthma,Epilepsy

PERSONAL HISTORY:
Diet:Mixed
Appetie:Normal
Sleep:Normal
Bladder and Bowel movements:Normal 
GENERAL EXAMINATION:
Patient is conscious coherent cooperative

Vitals on admission:
Temp- 98.5F
Bp- 110/70mmhg
PR-  82 bpm
RR- 20cpm
 pallor+,no icterus,cyanosis,clubbing,lymphadenopathy,oedema
SYSTEMIC EXAMINATION:
Cvs-S1 S2+,No murmurs heard
RS- Bilateral air entry present,Normal vesicular breath sounds present 
CNS- HMF intact,NFD
P/A- soft, non tender

Investigations:

Hemogram:

Fever chart:
Usg abdomen:
Ecg:
2d echo:
Chest x ray:
Diagonosis:
Pyrexia with thrombocytopenia


Treatment:
IVF NS,RL@100ml/hr
T.Pcm 650mg po sos
T.Pan 40mg po/od
T.Zofer 4mg po/sos
Plenty of oral fluids 
Vitals monitoring 4th hourly

10/1/23:

60 year old Female came with 
C/O Fever since 2 days 
C/O Head ache since evening 

GM unit 4 
Dr Susmitha SR
Dr Shashikala PGY 3
Dr Keerthi PGY2
Dr Navya PGY1
Dr Rahul sai(Intern)
Dr Vyshnavi (Intern)
Ward
Day - 2

S
Fever subsided 
Head ache subsided 
No fresh complaints 
O
Patient is conscious coherent and cooperative
Temp- 98.5F
Bp- 110/70mmhg
PR-  82 bpm
RR- 20cpm
Cvs-S1 S2+,No murmurs heard
RS- Bilateral air entry present,Normal vesicular breath sounds present 
CNS- HMF intact,NFD
P/A- soft, non tender

A
Pyrexia with thrombocytopenia
Anemia secondary to ? Iron deficiency 
P
IVF NS,RL@100ml/hr
T.Pcm 650mg po sos
T.Pan 40mg po/od
T.Zofer 4mg po/sos
Plenty of oral fluids 
Vitals monitoring 4th hourly

11/1/23
Ward
Day - 3

S
Fever subsided 
Head ache subsided 
No fresh complaints 
O
Patient is conscious coherent and cooperative
Temp- 98.5F
Bp- 140/80mmhg
PR-  84 bpm
RR- 20cpm
Cvs-S1 S2+,No murmurs heard
RS- Bilateral air entry present,Normal vesicular breath sounds present 
CNS- HMF intact,NFD
P/A- soft, non tender

A
Pyrexia with thrombocytopenia
Anemia secondary to? iron deficiency 

P
IVF NS,RL@100ml/hr
T.PCM650mg po sos
T.OROFER- XT PO/OD
Plenty of oral fluids 
Vitals monitoring 4th hourly

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