A 28 YR OLD FEMALE WITH RASH OVER RT FOREARM , loss of appetite &vaginal discharge
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A 28 year old female came to casualty with
Complaints of:
Loss of appetite since 3 days
Vaginal discharge since 1month
Rash over the forearm since 5 days
History of presenting illness:
Patient was apparently asymptomatic 3 days back then she developed Rash over the forearm since 5 days which was sudden in onset .No h/o trauma to the forearm
Pt had vaginal white discharge since 1month
Not associated with foul smelling ,itching not relieved by medication.
Past history :
H/o rash over RT knee joint 10 days back relieved on application of (zandu balm)
H/o HYPOTHYROID
IN 2018 -During 1st pregnancy TAB.THYRONORM 25MCG for 6months
In 2021- During 2nd pregnancy in 2nd month
TAB.THYRONORM 50MCG for 7months
N/K/C/O HTN,DM,TB,CAD,ASTHMA
GENERAL EXAMINATION
Patient is Conscious, coherent,co operative well oriented to Time,place,person
No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema
Rash over RT.forearm
VITALS
Temperature -97.3F
Pulse rate- 80bpm
Blood pressure-110/70mm hg
Respiratory rate -19cpm
GRBS -136 mg/dl
SYSTEMATIC EXAMINATION:
PER ABDOMEN:Soft, non tender
No guarding, No rigidity
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs
RESPIRATORY SYSTEM:
BAE present,NVBS
CENTRAL NERVOUS SYSTEM:
NAD
Provisional Diagnosis:
THROMBOCYTOPENIA UNDER EVALUATION
INVESTIGATIONS:
Chest x ray PA view
Treatment : on 10/4/22
1)IVF -NS @100ML/HR
-RL
2)INJ.NEOMOL 1GM IV/SOS (IF TEMP.>100F)
3)INJ.PANTOP 40MG IV/OD
4)INJ.ZOFER 4MG IV/SOS
5)TAB.PCM 500MG PO/TID
6) TEMPERATURE CHARTING
7)I/O CHARTING
On 11/4/22
SOAP NOTES (AMC bed
S- pain in both lower limbs
O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE.
ICTERUS +
NO PALLOR ,ICTERUS ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.
VITALS-
TEMPERATURE - 98.3F
PULSE RATE -78bpm BPM,REGULAR ,NORMAL VOLUME
BLOOD PRESSURE - 110/ 80MM OF HG
SPO2 - 98% AT RA
GRBS - 110 mg/dl
On
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY
CVS : S1 S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS
CNS : NAD
A - THROMBOCYTOPENIA UNDER EVALUATION
P -
1)IVF -NS @100ML/HR
-RL
2)INJ.NEOMOL 1GM IV/SOS (IF TEMP.>100F)
3)INJ.PANTOP 40MG IV/OD
4)INJ.ZOFER 4MG IV/SOS
5)TAB.PCM 500MG PO/TID
6) TEMPERATURE CHARTING
7)I/O CHARTING
