BY,M.Logeshwary

A three and half year old female child patient was admitted in hospital on 26/10/2016

Chief complaints:

c/o fever for 1 week,high grade and intermittent

c/o headache ,myalgia

c/o cold/cough and sore throat for 4 weeks

c/o vomitting for 4 days soon after feeds

c/o loose stools for 2 days not blood stained

c/o abdominal pain

c/o chills/rigors

c/o fatigue

History of present illness No h/o of jaundice/seizures/skin rashes/bleeding

manifestations

No h/o dysuria

Past medical history:

Nil

Past medication history:

Nil

Personal histoy:

Birth h/o:LSCS , BW:2.75 kg

Developmentally normal

Immunised upto age

Physical examination Patient is concious

No pallor

No cyanosis

No clubbing

No edema

No icterus

On examination:

Temp: 100.3 F

RR: 14 cycles/min

HR: 88 beats/min

Systemic examination:

CVS: S1S2 +

RS : NVBS

CNS : NFND

P/A : soft

PARAMETERS OBSERVED VALUES NORMAL VALUES

Hb 9.8 g/dl 11-13 g/dl

Neutrophills 60% 23-54%

Lymphocytes 38% 35-65%

Eosinophills 2 % 1-6%

Platelet 2.1 lakhs /mcl 1.5-4.5 lakhs/mcl

Total count 11200cells /mm 4000-11000cells/mm

Lab investigations

Other test:

Blood widal test

Chest X-ray

Impression:

Widal test – 1:160 dilutions positive

Chest X ray normal

Diagnosis:

TYPHOID FEVER

DRUGS DOSE R.O.A FREQ DURATION

IVF isolytic fluid 40ml/hr IV 0-24 hrs

ORS(Oral RehydrationSolution)

Sachet SOS

Cap.Bifilac Sachet p/o Bd

Syp.Zinc 5ml p/o Od

Inj.Emeset(ondansetron) 1cc IV Bd

Inj.Rantac(ranitidine) 1cc IV Bd/Od

T.Para(acetaminophen) 500mg p/o ½ qid / sos

Inj.Taxim(cefotaxime) 20mg/ml IV Bd

Syp.Waltuz Br(ambroxalcombination)

3.5ml p/o Bd

DMO REVIEW : T.Ambronac(ambroxalcombination)

200mg p/o Bd

DRUG CHART

Medication error:

Nil

Drug interaction:

Nil

Discharge advice:

The patient is continuing the treatment and is advised to strictly adhere to the drug regimen.

Patient counselling:

The patient is advised to take light diet foods , take rest , keep the hands clean , also maintain the environment around the child clean and also consume clean water. Continue the drug regimen.

SOAP NOTES Subjective:

A three and half year old female child was admitted in hospital with chief complaints of fever for 1 week , high grade and intermittent , headache , myalgia , cold/cough and sore throat for 4 weeks , vomiting for 4 days soon after feeds, loose stools for 2 days not blood stained , abdominal pain ,chills/rigors , fatiguability.

Objective:

Hb level is low in this patient. Neutrophills and total count is increased. Widal test and chest X ray is also taken in this patient since this patient has high grade of cough , cold and fever

Assesment:

On assessing the patients lab investigations of low Hblevels the patient is very weak, and as the total count and neutrophills are increased the patient should have suffering from any sort of infections. Widal test shows positive on 1:160 dilutions , so the patient is diagnosed to have TYPHOID FEVER, and chest ray seems to be normal for this patient

Plan of treatment: IVF isolytic fluid and ORS powder is given as this patient is

suffering from heavy dehydration due to loose stools and vomiting for past 4 days.

Bifilac capsule is generally given for GI disorders and diarrhea in children. It is given for this patient as this patient is suffering from diarrhea.

Tablet zinc is given for best uptake of ORS and is also used for the treatment of diarrhea.

Injection ondansetron is given as anti-emetic to avoid vomiting. Injection ranitidine is given to avoid ulcer, stomach pain and

heart burn. This also give some relief from cold and cough.

Since the patient is suffering from high grade intermittent fever tablet acetaminophen is given.

Injection taxim is given as antibiotic for typhoid fever as this line of cephalosporins act as first line drug in typhoid.

Syrup waltuz br is ambroxal combination which act as expectorant and bronchodilator and gives relief on cough , chest compression, chest tightness , thickened mucus cough.

Since acetaminophen is given for this child continuously toxicity may occur. To avoid this tablet ambronac is given which prevents the paracetamol toxicity and it also act as mucolytic and mucokinetic

THANK YOU