Viral Pyrexia with umbilical hernia
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Unit 3 Admission
A 34y/o female patient came to the casuality with the chief complaints of
1. Fever since 2 days
2. Loose stools 2 - 3 episodes
Fever is of low grade, not a/w chills and rigors, a/w head ache, reduced on medication. No H/o nausea, vomitings. H/o 2-3 episodes of loose stools. No h/o bleeding manifestations.
H/o 3 LSCS for her 3 previous pregnancies.
H/o pre eclampsia in all 3 pregnancies.
Not a k/c/o DM, HTN, TB, asthma, epilepsy.
She is a married homemaker. She takes mixed diet.
Appatite normal
Sleep adequate
Bladder regular
Bowel 2-3 episodes of loose stools
No addictions.
O/E
O/E
Pt is c/c/c
Well built and nourished
Afebrile (98.5F)
No icterus, cyanosis, lymphadenopathy, clubbing, lower limb pitting edema.
BP 110/80 mmHg
PR 92 bpm
RR 18 cpm
SpO2 97% in room air
GRBS 101 mg/dl
CVS
S1 S2 heard
No thrills and murmurs
RS
Dyspnoea -
Wheeze -
Trachea central
Breath sounds vesicular
P/A
Obese abdomen
Distended
Non tender
No palpable mass
Liver and spleen not palpable
No free fluid
Bowel sounds +
CNS
Pt is conscious
No signs of neck stiffness
Power 5/5 in all 4 limbs
Pupils NSRL
Reflexes are all +2
Prov Diagnosis
Viral Pyrexia with thrombocytopenia with umbilical hernia
USG abdomen
1. Gall bladder wall edema
2. Umbilical hernia (1.4cm defect noted at umbilical region with omentum as content, no e/o strangulation/obstruction)
3. Mild hepatomegaly
SOAP NOTES DAY 1
Ward Patient
General Surgery cross consultation taken. Diagnosis of umbilical hernia confirmed. Adviced to review at Gen Surgery opd after discharge.
S
Pt is C/C/C
Diffuse abd tenderness
No fever spikes
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile (97.5 F)
BP 110/80 mmHg
PR 78 bpm
RR 18 cpm
SpO2 97 at room air
A
Viral Pyrexia with thrombocytopenia with umbilical hernia
P
1. IVF NA,RL at 100ml/hr
2. Inj PAN 40mg iv/od
3. Inj ZOFER 4mg iv/sos
4. Tab DOLO 650mg po/sos
5. Inj NEOMOL 1gm iv (if temp more than 101 F)
6. BP, PR, RR, Temp monitoring
7. W/f bleeding manifestations
SOAP NOTES DAY 2
Ward Patient
S
Pt is C/C/C
Diffuse abd tenderness
No fever spikes
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile (98.4 F)
BP 90/80 mmHg
PR 76 bpm
RR 16 cpm
SpO2 98 at room air
A
Viral Pyrexia with thrombocytopenia with umbilical hernia
P
1. IVF NA,RL at 100ml/hr
2. Inj PAN 40mg iv/od
3. Inj ZOFER 4mg iv/sos
4. Tab DOLO 650mg po/sos
5. Inj NEOMOL 1gm iv (if temp more than 101 F)
6. BP, PR, RR, Temp monitoring
7. W/f bleeding manifestations
SOAP NOTES DAY 3
Ward Patient
S
Pt is C/C/C
Diffuse abd tenderness
No fever spikes
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile (98.4 F)
BP 110/80 mmHg
PR 102 bpm
RR 20 cpm
SpO2 95 at room air
A
Viral Pyrexia with thrombocytopenia with umbilical hernia
P
1. IVF NA,RL at 100ml/hr
2. Inj PAN 40mg iv/od
3. Inj ZOFER 4mg iv/sos
4. Tab DOLO 650mg po/sos
5. Inj NEOMOL 1gm iv (if temp more than 101 F)
6. BP, PR, RR, Temp monitoring
7. W/f bleeding manifestations
