A 70 year old female with chief complaints of fever and polyuria

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August 09, 2021

70Y/F

Unit 6 admission

A 70 year old female patient came to the OPD with chief complaints of fever since 3 days and polyuria since 3 days.

CHEIF COMPLAINTS:

• Fever since 3 days

• Polyuria since 3 days

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 3 days back then she developed fever associated with chills and rigor present throughout the day relieved after taking medication

• No diurnal variation 

• No C/O cough ,shortness of breath 

• C/O headache since 3 days(diffuse type) 

• C/O  decreased appetite since 3 days not associated with nausea vomiting. 

Patient was taken to katangur 3 days back I/v/o fever was given some medications(unknown) and was told she has high sugar (300  mg/dl) 

• No H/O chest pain

• No H/O palpitation

• No H/O burning micturition

• No H/O pedal edema

HISTORY OF PAST ILLNESS-

• k/c/o DM, HTN since 3 months. 

TREATMENT HISTORY-

• T. METFORMIN 500 mg/ po/BD.

• T. ATEN 50/ po/ BD. 

- has no treatment history of asthma,  TB

PERSONAL HISTORY-

Is married and daily wage labourer 

• appetite -normal 

• vegetarian

• Bowel and bladder movements are regular

• No known allergies

• No addictions

FAMILY HISTORY-

• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases. 

GENERAL EXAMINATION-

• Pallor - no

• No cyanosis, icterus

• No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition. 

• Dehydration - mild

Vitals :

• PR - 98bpm ( irregular) 

• RR - 22 cycles/min

• BP - 110/80 mmHg

• Temp. 103.3°F

• GRBS -  116 mg/dl

• SPO2- 81%

SYSTEMIC EXAMINATION-

A. Cardiovascular system :

• S1, S2 are heard

• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing

• Position of trachea - central

• Breath sounds - Vesicular

• crypts Heard at left ICA

C. Per Abdominal Examination:

Shape of abdomen - scaphoid

• No Tenderness 

• No palpable mass , free fluids, bruits

• Liver, spleen not palpable

• there are Bowel sounds

D. Central Nervous :NAD

INVESTIGATIONS:

1. CHEST X RAY:

2. ECG:

3. ULTRASOUND:

4. ABG:

5. RANDOM BLOOD SUGAR:

6. BLOOD UREA:

7. SERUM CREATININE:

8. SERUM ELECTROLYTES( Na, K, Cl ):

9. DENGUE NS1 Antigen, IgG & IgM( RAPID TEST ):

10. HBsAg- RAPID:

11. HIV 1/2 RAPID TEST:

12. ANTI HCV ANTIBODY - RAPID:

PROVISIONAL DIAGNOSIS-

Fever under evaluation

? COVID-19 Pneumonia

TREATMENT:

Day 1:  07/08/2021

1. IVF RL & NS @ 50 ml/hr with 1 amp of optineuron 

2. Tab PAN 40 mg/PO/OD

3. Tab Zofer 4mg/PO/SOS

4. Tab Dolo 650 mg/ PO/OD

       1——1——1

5. Tab Azithromycin 500 mg/PO/OD

       1——x——x

6. Inj NEDMOL 100ml/IV/SOS ( If temperature > 101 F )

7. O2 Inhalation if SpO2 < 90% @ Room air

8. Temperature charting 4th hourly 

9. BP/PR/SpO2 Charting 4th hourly

Day 2:  08/08/2021

1. IVF RL & NS @75ml/hr

2. Inj MONOCEF 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

      1——x——x

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

     1——1——1

Day 3: 09/08/2021

1. IVF RL & RS @75ml/hr

2. Inj Monocef 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

7. GRBS Charting 6th hourly

8. O2 Inhalation if SpO2 < 90% of room air

9. Temperature charting 1 hourly 

10. Strict I/O Charting 

Day 4: 10/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

 6. O2 Inhalation if SP O2 < 90% of room air.

 7.Temperature charting 1hrly.

 8. strict I/O charting.

Day 5: 11/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

 6. O2 Inhalation if SP O2 < 90% of room air.

 7.Temperature charting 1hrly.

 8. strict I/O charting.

Day 6: 12/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.Tab Pan 40 mg PO/OD

3.Tab zofer 4 mg iv/bd

4.Tab Dolo 650 mg PO/TID 

5.GRBS charting 6th hourly 

6.O2 inhalation if SpO2 < 90% of room air

7.Temperature charting 1 hourly 

8. Strict I/O charting

Day 7: 13/08/2021

1.INJ.MONOCEF 1gm/iv/bd

DISCHARGE SUMMARY:

Unit 6 admission

A 70 year old female patient came to the OPD with chief complaints of fever since 3 days and polyuria since 3 days.

CHEIF COMPLAINTS:

• Fever since 3 days

• Polyuria since 3 days

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 3 days back then she developed fever associated with chills and rigor present throughout the day relieved after taking medication

No diurnal variation 

No C/O cough ,shortness of breath 

C/O headache since 3 days(diffuse type) 

C/O decreased appetite since 3 days not associated with nausea vomiting. 

Patient was taken to katangur 3 days back I/v/o fever was given some medications(unknown) and was told she has high sugar (300 mg/dl) 

no H/O chest pain

no H/O palpitation

no H/O burning micturition

no H/O pedal edema

PAST ILLNESS-

k/c/o DM, HTN since 3 months. 

TREATMENT HISTORY-

T. METFORMIN 500 mg/ po/BD.

T. ATEN 50/ po/ BD. 

- has no treatment history of asthma, TB

PERSONAL HISTORY-

Is married and daily wage labourer 

appetite -normal 

vegetarian

Bowel and bladder movements are regular

No known allergies

No addictions

FAMILY HISTORY-

• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases. 

GENERAL EXAMINATION-

• Pallor - no

• No cyanosis, icterus

• No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition. 

• Dehydration - mild

Vitals :

• PR - 98bpm ( irregular) 

• RR - 22 cycles/min

• BP - 110/80 mmHg

• Temp. 103.3°F

• GRBS - 116 mg/dl

• SPO2- 81%

SYSTEMIC EXAMINATION-

A. Cardiovascular system :

• S1, S2 are heard

• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing

• Position of trachea - central

• Breath sounds - Vesicular

• crypts Heard at left ICA

C. Per Abdominal Examination:

• Shape of abdomen - scaphoid

• No Tenderness 

• No palpable mass , free fluids, bruits

• Liver, spleen not palpable

• there are Bowel sounds

D. Central Nervous :NAD

PROVISIONAL DIAGNOSIS-

Fever under evaluation

? COVID-19 Pneumonia

CURB 65 score for her at admission was 4/5.

Subjectively- pt feeling better

SOB subsided

Pt is regaining apetite.

No oxygen requirement from morning.

Objectively- c/c/c

Febrile-101 F

Repiratory rate-18cpm

Spo2 on RA- 93%

BP- 110/60

Resp- mild inspiratory crepitations B/L Infra axillary area.

Assessment- L lower lobe pneumonia.

Plan- continuing same antibiotics.

SOAP NOTES:-

SOAP NOTES DAY 1

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

Pt C/o fever

   C/o weakness

OBJECTIVE:

Temperature-101 F

Bp-110/70 mmhg

PR- 86 bpm

RR -16 cpm

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1. IVF RL & NS @ 50 ml/hr with 1 amp of optineuron 

2. Tab PAN 40 mg/PO/OD

3. Tab Zofer 4mg/PO/SOS

4. Tab Dolo 650 mg/ PO/OD

       1——1——1

5. Tab Azithromycin 500 mg/PO/OD

       1——x——x

6. Inj NEDMOL 100ml/IV/SOS ( If temperature > 101 F )

7. O2 Inhalation if SpO2 < 90% @ Room air

8. Temperature charting 4th hourly 

9. BP/PR/SpO2 Charting 4th hourly

SOAP NOTES DAY 2

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

Pt C/o fever

   C/o weakness

OBJECTIVE:

Temperature-

• 102 F from 4 to 8 am

• 101 F at 12 am

• 104 F at 4 pm

• 39.5°C at 8 pm

• 101 F at 12 pm

Bp-130/80 mmhg

PR- 85 bpm

RR- 14 cpm

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1. IVF RL & NS @75ml/hr

2. Inj MONOCEF 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

      1——x——x

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

     1——1——1

SOAP NOTES DAY 3

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

Pt C/o fever

   C/o weakness

OBJECTIVE:

Temperature-

• 101 F at 4 am

• 39°C at 8 am

• 37.5°C at 12 am

• 98 F at 4 pm

• 98 F at 8 pm

• 100 F at 12 pm

Bp-110/60 mmhg

PR- 79 bpm

RR -17 cpm

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1. IVF RL & RS @75ml/hr

2. Inj Monocef 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

7. GRBS Charting 6th hourly

8. O2 Inhalation if SpO2 < 90% of room air

9. Temperature charting 1 hourly 

10. Strict I/O Charting  IVF RL & RS @75ml/hr

2. Inj Monocef 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

7. GRBS Charting 6th hourly

8. O2 Inhalation if SpO2 < 90% of room air

9. Temperature charting 1 hourly 

10. Strict I/O Charting 

SOAP NOTES DAY 4

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

Pt C/o fever

   C/o weakness

OBJECTIVE:

Temperature-

• 98 F at 4 am

• 37°C at 8 am

• 37.5°C at 12 am

• 99 F at 4 pm

• 37.5 °C at 8 pm

• 37.5 °C at 12pm

Bp-110/70 mmhg

PR- 78bpm

RR -23 cpm

Grbs-132 mg/dl

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE-

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

 6. O2 Inhalation if SP O2 < 90% of room air.

 7.Temperature charting 1hrly.

 8. strict I/O charting.

SOAP NOTES DAY 5 :

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

Pt C/o fever

   C/o weakness

OBJECTIVE:

Temperature-

• 99 F at 4 am

• 38°C at 8 am

• 102 F at 12 am

• 101 F at 4 pm

• 38 °C at at 8pm & 12pm

Bp-110/60 mmhg

PR- 80 bpm

RR -21 cpm

Grbs-172 mg/dl

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

6. O2 Inhalation if SP O2 < 90% of room air.

7.Temperature charting 1hrly.

8. strict I/O charting.

SOAP NOTES DAY 6 :

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE:

 C/o weakness

OBJECTIVE:

Temperature-

• 99 F at 4am&8am

• 38 °C at 12 am

• 100 F at 4 pm

• 98 F at 8 pm

• 38 °C at 12 pm

Bp-110/80 mmhg

PR- 82 bpm

RR -22 cpm

Grbs-153 mg/dl

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1.INJ.MONOCEF 1gm/iv/bd

2.Tab Pan 40 mg PO/OD

3.Tab zofer 4 mg iv/bd

4.Tab Dolo 650 mg PO/TID 

5.GRBS charting 6th hourly 

6.O2 inhalation if SpO2 < 90% of room air

7.Temperature charting 1 hourly 

8. Strict I/O charting 

SOAP NOTES DAY 7 :

A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA (LEFT LOWER LOBE PNEUMONIA)

SUBJECTIVE: 

 C/o weakness

OBJECTIVE:

Temperature-

• 99 F at 4 am

• 38 °C at 8 am

Bp- 80/50 mmhg

PR- 80 bpm

RR -21 cpm

ASSESSMENT-

Viral pyrexia(left lower lobe pneumonia)

K/c/o DM & HTN (10yr's)

PLAN OF CARE- 

1.INJ.MONOCEF 1gm/iv/nd

TREATMENT:

Day 1:  07/08/2021

1. IVF RL & NS @ 50 ml/hr with 1 amp of optineuron 

2. Tab PAN 40 mg/PO/OD

3. Tab Zofer 4mg/PO/SOS

4. Tab Dolo 650 mg/ PO/OD

       1——1——1

5. Tab Azithromycin 500 mg/PO/OD

       1——x——x

6. Inj NEDMOL 100ml/IV/SOS ( If temperature > 101 F )

7. O2 Inhalation if SpO2 < 90% @ Room air

8. Temperature charting 4th hourly 

9. BP/PR/SpO2 Charting 4th hourly

Day 2:  08/08/2021

1. IVF RL & NS @75ml/hr

2. Inj MONOCEF 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

      1——x——x

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

     1——1——1

Day 3: 09/08/2021

1. IVF RL & RS @75ml/hr

2. Inj Monocef 1ml/IV/SOS

3. Tab Azithromycin 500mg/PO/OD

4. Tab PAN 40mg/PO/OD

5. Tab Zofer 4mg/IV/SOS

6. Tab DOLO 650mg/PO/TID

7. GRBS Charting 6th hourly

8. O2 Inhalation if SpO2 < 90% of room air

9. Temperature charting 1 hourly 

10. Strict I/O Charting 

Day 4: 10/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

 6. O2 Inhalation if SP O2 < 90% of room air.

 7.Temperature charting 1hrly.

 8. strict I/O charting.

Day 5: 11/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.TAB.Azithromycin 500 mg/po/BD

3.Tab.PCM PO/TID

4. Tepid sponging 

5. GRBS Charting 6th hrly

 6. O2 Inhalation if SP O2 < 90% of room air.

 7.Temperature charting 1hrly.

 8. strict I/O charting.

Day 6: 12/08/2021

1.INJ.MONOCEF 1gm/iv/bd

2.Tab Pan 40 mg PO/OD

3.Tab zofer 4 mg iv/bd

4.Tab Dolo 650 mg PO/TID 

5.GRBS charting 6th hourly 

6.O2 inhalation if SpO2 < 90% of room air

7.Temperature charting 1 hourly 

8. Strict I/O charting

Day 7: 13/08/2021

1.INJ.MONOCEF 1gm/iv/bd

Course in hospital- 

75 yr old female admitted with complaints of fever from 3 days. Fever was intermittent type associated with chills and rigors. Along with fever pt also had complaints of shortness of breath,headache,loss of apetite.

Pt was managed conservatively with initial suspicion of viral pyrexia with no favourable response and no positive diagnostic test.Pt was given empirical antibiotic therapy and

fever subsided. It showed a typical step ladder pattern confirming diagnosis of Enteric Fever. With improvement in overall condition and resolution of above mentioned symptoms pt is being discharged with following medication and adviced for follow up after 1 week.

Advice at discharge

T Cefixime 200mg BD for 5 days

T pan 40 mg once daily for 5 days

T PCM 650mg sos

T MVT once daily for 5 days

T.metformin 500 mg once daily