Om Kumari Bishokarma, a 38-year-old female, was admitted to the hospital with a fever, headache, joint pain, and vomiting for the past 15 days. Tests revealed elevated inflammatory markers and a positive result for Scrub Typhus. She was treated intravenously with antibiotics, fluids, and pain medications. Her condition stabilized and she was discharged with oral medications, advised to follow up in 2 days.
1. Z
KATHMANDU MEDICAL COLLEGE& TEACHING HOSPITAL
Sinamangal, Kathmandu, Nepal
: 4476152, 4469064*
DISCHARGE
DEPARTMENT OF INTERNAL MEDICINE
Name of the patient: OM KUMARI BISHOKARMA
Age/Sex: 38YRS/FEMALE
IP no: 164494
Address: OKHALDHUNGA
Bed no: 123
Date of Admission: 2079/06/23
Date of Discharge: 2079/06/27
Case Summary
Patient was in her usual state of health 18 days back when she developed fever which was acute in onset, Tmax recorded was
101F associated with chills and rigor , joint pain, myalgia , relieved on taking oral medications.
She also complained of headache for 15 days , increasing in intensity since last 15 days , insidious in onset , gradually
progressive , global , associated with photophobia , vomiting.
She also had vomiting for 15 days , acute in onset , 4-5 episodes , containing food particles , non-bile and blood stained, non-
projectile .
No history of bleeding of gum and nose, black tarry stool.
No history of abnormal body movement, LOC, frothing from mouth, up-rolling of eyes.
No history of loose stool , abdominal pain , hematuria , burning micturition.
Past history:
History of headache since last 15 years relieved on taking medicines .
No history of DM, HTN, thyroid disorder .
Personal history:
Non-smoker and non-alcoholic .
EXAMINATION AT THE TIME OF ADMISSION:
On examination:
S/E:
Chest: NVBS, no added sounds
CVS: S1S2M0
P/A: Soft, non-tender , non distended.
CNS: GROSSLY INTACT , no signs of meningeal irritation.
INVESTIGATIONS 2079/06/23 2079/06/26
HB/PCV 12.2
TC 5900
DC(N-L) 41-55
PLATELETS 15700
CRP Q 266 30
UREA/CR 19/0.6
NA/K 136/3.8
TB/DB 0.7/0.3
SGPT/SGOT/ALP 346/260/596
URINE RME ALBUMIN: NIL
G/C – ill looking , headache in supine position
PILCCOD- NIL
VITALS:
Temp: 102.4 F
Pulse: 78 pm
RR- 20/min
BP- 100/70mm of Hg
SPO2-98% in RA
DIAGNOSIS: RICKETTSIAL FEVER ( SCRUB IgM + , IgG +)
DEPARTMENT OF INTERNAL MEDICINE
PROF DR. MATHURA KC
ASST. PROF. DR. SUBASH PANT
DR. ALOK DHUNGEL
DR. ANANTA ARYAL
DR. SUNIL ACHARYA
DR. ABISHKAR ACHARYA
2. Z
PUS CELLS : 1-3
EPI CELLS : 2-3
RBC : NIL
BLOOD C/S NO GROWTH
URINE C/S NO GROWTH
SCRUB TYPHUS
IgG/IgM
POSITIVE
WIDAL NEGATIVE
PERIPHERAL BLOOD SMEAR : (2079/06/25)
RBC MORPHOLOGY : NORMOCYTIC NORMOCHROMIC WITH MILD ANISOCYTOSIS
WBC : WITHIN NORMAL LIMIT
PLATELETS : ADEQUATE
ABNORMAL CELLS NOT SEEN
Treatment in the Hospital:
Patient presented to ER and was admitted to general medicine WARD and where he was evaluated and managed with, IV FLUIDS, INJ
ACILOC, INJ ONDEM , INJ DOXYFEE, INJ KETOROLAC, INJ PANTOP , INJ MONOCEF , INJ THERMODOL , and other
supportive management. He is being discharged after his vitals are stable.
CONDITION AT DISCHARGE:
VITALS:
Pulse: 90bpm
RR: 20min
Temp: 98.2F
BP: 110/70mm of Hg
SpO2: 96% in RA
TREATMENT AT DISCHARGE
1. TAB MUCOACE 600 MG PO TDS
2. TAB LOCET 5 MG PO HS CONTINUE
3. TAB DOXY 100MG PO BD
ADVICE:
DRINK PLENTY OF FLUIDS .
FOLLOW UP IN MEDICINE OPD IN 2 DAYS/SOS WITH CBC, PCV REPORTS
____________________
SIGNATURE OF RESIDENT
DR. LAXMAN KHATI
NMC NO : 26732
G/C: Fair
PILCCOD –Nil
S/E:
P/A: Soft, non-tender, bowel sound present.
RS: NVBS, B/L equal air entry
CVS: S1S2M0
CNS: Grossly intact
