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A 42 year old women with persistent cough




This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 


42 year old female presented with complaints of 
Cough since 1 month
Fever since 1 day

Hopi:
Patient was apparently asymptomatic 1 month ago then she developed cough which was dry and did not subside on medication 

Patient had fever 1 month ago which was high grade, continuous, and it lasted for 1 week. Now she again has been having fever since 1 day which is high grade and continuous. Not associated with chills and rigors 

Past history:
She's not a known case of diabetes mellitus, hypertension, asthma, epilepsy, TB.

Personal history:
Appetite - normal
Diet- mixed
Bowel and bladder movements- regular
Sleep- disturbed due to cough
No addictions 

General examination:
Pallor yes
Icterus no
Cyanosis no
Clubbing no
Lymphadenopathy no
Generalised edema no
Malnutrition no


Temp- 101F
Bp- 110/80 mmHg
Pr- 139bpm
Rr- 26cpm
Spo2- 97% @RA
GRBS- 126mg/dl
 


Cardiovascular System : S1, S2 heard, no murmurs

Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.

Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 

Per abdomen : soft, non tender. No organomegaly.

Investigations:















USG chest-


USG abdomen-


ECG -

Chest Xray-


Treatment:
IVF 1 DNS @75ml/hr
       1 RL @75ml/hr
Inj Neomol 1 gm iv sos if temp >101F
Tab Dolo 650mg PO TID
Tab Pan 40mg PO OD
Monitor temperature and vitals 4th hourly

23/12/22 SOAP NOTES
42 year old female
GM unit 4 
AMC bed- 5
Day - 1

S
Fever subsided
Cough subsided

O
Patient is conscious coherent and cooperative
Temp- 97.4F
Bp- 110/80 mmHg
Pr- 89bpm
RR- 20cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender


A
Viral pyrexia with thrombocytopenia

P
IVF 1 DNS @75ml/hr
       1 RL @75ml/hr
Inj Neomol 1 gm iv sos if temp >101F
Tab Dolo 650mg PO TID
Tab Pan 40mg PO OD
Monitor temperature and vitals 4th hourly



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