Narrative Note Medicine case (Scrub Typhus Case)

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 📝 Narrative Note (Scrub Typhus Case)


Patient presented with high-grade fever for 7 days, associated with chills, headache, and generalized body pain. Patient reported outdoor exposure in agricultural fields. On examination: temperature 102°F, pulse 110/min, BP 100/70 mmHg, presence of eschar on right axilla, and mild hepatosplenomegaly. Patient appeared anxious and weak. Informed Dr. Mishra (Obstetrician & Physician on duty) regarding suspected scrub typhus. Blood investigations showed thrombocytopenia and elevated liver enzymes. Patient educated about disease transmission and importance of early treatment. Supportive care initiated, and doxycycline therapy discussed with medical team.

📌 SBAR Format
•     S (Situation): Patient admitted with persistent fever, chills, and weakness. Eschar noted in right axilla.
•     B (Background): History of outdoor exposure in endemic area. Past medical history unremarkable.
•     A (Actions taken): Informed Dr. Mishra. Sent blood samples for CBC and LFT. Initiated IV fluids, antipyretics, and supportive care. Discussed doxycycline therapy with medical team. Educated patient about disease and prevention.
•     R (Recommendation): Monitor vitals every 4 hours. Assess platelet count daily. Continue antibiotics as per physician’s order. Provide patient counseling on avoiding mite exposure in future.

📋 SOAP Format
•     S (Subjective): Patient stated, “I have had fever with chills and severe body pain for a week. I feel very weak.”
•     O (Objective): Temp 102°F, pulse 110/min, BP 100/70 mmHg. Eschar noted in axilla. CBC shows thrombocytopenia; LFT deranged.
•     A (Assessment): Acute febrile illness likely scrub typhus. Risk of complications (hepatitis, meningoencephalitis).
•     P (Plan): Informed Dr. Mishra. Initiated IV fluids, antipyretics, and antibiotics (doxycycline). Monitor vitals and labs. Educate patient on disease prevention.

📑 PIE Format
•     P (Problem): Patient with fever, chills, weakness, eschar, and thrombocytopenia—suspected scrub typhus.
•     I (Intervention): Notified Dr. Mishra. Sent investigations. Started IV fluids, antipyretics, and antibiotics. Provided patient education.
•     E (Evaluation): Patient reported relief in fever after 24 hours of therapy. Expressed understanding of disease and preventive measures.

📂 Focus/DAR Charting
•     D (Data): Patient presented with fever, chills, weakness, eschar in axilla, and abnormal labs.
•     A (Action): Informed Dr. Mishra. Initiated supportive care and antibiotics. Educated patient about scrub typhus and prevention.
•     R (Response): Patient reported feeling better after initiation of therapy. Expressed relief and willingness to follow preventive advice.
•     P (Plan): Continue monitoring vitals and labs. Maintain hydration. Provide counseling on avoiding mite-infested areas.

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