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Discharge Summary:
Day 6 of illness
Day 2 Afebrile 12/2
6 days prior to consult, patient noted to have fever of 38C with associated vomiting
post-prandial and loose BM for 2x.
4 days prior, patient symptoms persisted and opted private MD consult and was
given Co-trimoxazole, ORS and Paracetamol 10mkd.
3 days prior, the patient noted decrease in frequency of LBM but now with
associated myalgia.
1 day prior, the patient noted bleeding on the gum area post-brushing of teeth and
maculopapular rashes on the upper extremities.
Few hours prior noted 1 episode of epistaxis, hence consult at ER.
Upon admission, the patient was hooked to IV and PLR 3 was started. Diagnostics
were requested: CBC with PC, ABO typing and PT PTT. The following medications
were started: 1) ORS 1 sachet in 200mL water as tolerated and 2) Paracetamol
250mg/5mL every 4 hours for temperature >37.8 C. Vital signs were closely
monitored every four hours as well as input and output every shift. Serial CBCs were
obtained to monitor hemoconcentration and thrombocytopenia. The rest of the
hospital stay was unremarkable. on the second hospital day, the patient was
cleared for discharge
Home Medications:
1, Oral Rehydrating Solution, 1 sachet in 200mL water, 2L a day
2. Ascorbid acid once a day
No strenuous activities for 1 week
To come back anytime if with problems
Well advised