35 yr old female -viral pyrexia under evaluation

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35yr old female presented with complaints of fever since 10days
Pain abdomen since 10days
Generalised weakness since 10days 
Vomitings since 10days
Loose stools since 10days
Burning micturition since 10days

Hopi
Pt was apparently asymptomatic 10days ago then she had 
FEVER which is low grade , continuous and is associated with chills 
She has taken Dolo 650mg 3,4 per day for fever for 10days
It is also associated with VOMITINGS-non projectile, non bilious and non blood stained (2-3episodes per day) food particles as contents. 
also associated with LOOSE STOOLS 5 days ago- 2-3 episodes per day. Now subsided 

Past illness
She had TB 8yrs back ,ATT for 6months then she was relieved 
N/k/c/o DM,HTN, epilepsy, asthma, cad,cvd
LSCS done 15yrs ago and Tubectomy done 14yrs ago
No h/o blood transfusions 

Personal history 
Daily wage worker
Decreased appetite since 15days
No allergies and addictions 

General examination:
Pallor yes
Icterus no
Cyanosis no
Clubbing no
Malnutrition no

SOAP NOTES OF 16-12-22 (DAY-2)

S

C/o 
1. fever - subsided 
2. pain abdomen 
3. Generalised weakness 
4. Vomitings- subsided 
6. burning micturition since 10 days

O
Pt is conscious coherent and cooperative
Temp: 98.9F
BP: 130/80mmhg
PR: 70bpm
RR: 16 cpm

CVS: S1 S2 +
RS: BAE+
CNS: NAD
P/A: Soft and non tender

A

?viral pyrexia under evaluation

P

T PCM 650 mg/po/tid
T Cetrizine po/of
Syp Ascoril D 15ml po/tid
T zofer 4mg po/bd
T mvt po/od
T orofer XT po/of
T pan 40 mg po od



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