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55 year old female with fever, cough and difficulty in breathing

55 year old female with fever,cough and difficulty in breathing.


 This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

CASE HISTORY 

A 55 year old female came to casualty  with c/o

Fever since 3 days 

Cough since 3 days 

Difficulty in breathing since 3days 

HOPI:

Pt was apparently asymptomatic  3 days ago , then she developed fever which is low grade , relieved on medication 

She also has cough since 3 days which is dry

Then she developed increased fever since evng and increased cough and difficulty in breathing 

Abdominal discomfort since today evng 

No h/o nausea, vomiting 

No h/o loose stools

No h/o constipation 


PAST HISTORY:

K/C/O  type 2 DM since 15 years

K/C/O HTN since 10 years

Not a k/c/o TB/Epilepsy/Asthma/CVA/CAD


Personal History :

Diet : mixed
Appetite : Decreased
Sleep : Disturbed
Bowel movements : Normal 
Bladder movements : Decreased urine output 

On Examination :

Patient is conscious, coherent and cooperative.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.


















VITALS :
AT THE TIME OF ADMISSION :
TEMP. : 98.6 F
PR : 94 BPM
RR : 28 CPM
BP : 150/80 MM HG
SpO2 (on Room air) : 98%
GRBS : 501 mg/dl( 10 pm)

On Systemic Examination:

CVS : S1, S2 heard
RS : BAE present
P/A : soft, Non tender
CNS : HMF Intact



HEMOGRAM 



Blood grouping and Rh typing



Blood for M.P. strip test



RBS




LFT

Blood urea


Serum creatinine 


Serum electrolytes 








ABG


































Hb-9.9
TLC-11,500
PT COUNT-4.37

Na+  - 135
K+  - 3.2
Cl-   -  104


PROVISIONAL DIAGNOSIS:

TYPE 2 DM WITH UNCONTROLLED SUGARS WITH PYREXIA UNDER EVALUATION 

TREATMENT:

1. INJ.HAI 6 U IV STAT
2. INFUSION HAI 1ml in 39 ml NS/IV INFUSION OVER 6 ml/hr
3.STOP INFUSION IF GRBS<200MG/DL
4.IV FLUIDS NS@100ML/HR
5.INJ.PAN 40 MG IV/OD
6.INJ.ZOFER 5 MG IV /SOS
7.TAB.PCM 650 MG/PO/TID
8.INJ.AUGMENTIN 1.2GM IV /BD
9.INJ. NEOMOL 1GM IV/SOS(IF TEMP>101F


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