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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
Investigations :
On 14/10/22
HEMOGRAM
Blood grouping and Rh typing
Blood for M.P. strip test
RBS
LFT
Blood urea
Serum creatinine
Serum electrolytes
ABG
Chest x ray
On 15/10/22
On 16/10/22
On 18/10/22
On 19/10/22
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)
10.SYP. ASCORYL 10 ML PO/BD
11.GRBS MONITORING HOURLY
12.MONITOR VITALS
AMC BED 3
DAY 2(16/10/22)
S:
Dry cough associated with chest pain
O :
Patient is conscious, coherent and co-operative
Temp : 99.5 F
BP : 120/70 mmHg
PR : 102 BPM
RR : 26 CPM
SpO2 : 98%
GRBS : 179 mg/dl
A:
TYPE 2 DM WITH UNCONTROLLED SUGARS WITH PYREXIA UNDER EVALUATION
P:
1.INJ.HAI SC/TID
2.INJ.NDH SC/TID
3.IV FLUIDS @100ML/HR
4.INJ.AUGMENTIN 1.2GM/IV/BD
5.T.AZITHROMYCIN 500MG PO/OD
6.INJ.PAN 40 MG IV/OD
7. INJ.ZOFER 4MG IV SOS
8.INJ.NEOMOL 1GM IV SOS(IF TEMP>101F)
9.T.PCM 650 MG PO/TID
10.SYP.ASCORYL-D 10 ML PO/TID
11.GRBS MONITORING 7 POINT PROFILE
12.VITALS MONITORING
GRBS MONITORING:
8 AM-130MG/DL
10 AM-166 MG/DL
12 PM-214 MG/DL
4PM-204 MG/DL
8 PM-157 MG/DL
12 AM-78 MG/DL
2 AM-281 MG/DL
AMC BED 3
DAY 3(17/10/22)
S:
Dry cough associated with chest pain
O:
Patient is conscious, coherent and co-operative
Temp : 98.4 F
BP : 110/80 mmHg
PR : 90 BPM
RR : 26 CPM
SpO2 : 98%
GRBS : 130 mg/dl
A:
TYPE 2 DM WITH UNCONTROLLED SUGARS WITH PYREXIA UNDER EVALUATION
P:
1.INJ.HAI SC/TID
2.INJ.NDH SC/TID
3.IV FLUIDS @100ML/HR
4.INJ.AUGMENTIN 1.2GM/IV/BD
5.T.AZITHROMYCIN 500MG PO/OD
6.INJ.PAN 40 MG IV/OD
7. INJ.ZOFER 4MG IV SOS
8.INJ.NEOMOL 1GM IV SOS(IF TEMP>101F)
9.T.PCM 650 MG PO/TID
10.SYP.ASCORYL-D 10 ML PO/TID
11.NEN.BUDECORT DUOLIN
12.SYP.BENADRYL 10ML PO/TID
13.T.ULTRACET 1 TAB/PO/BD
14.VITALS MONITORING 4TH HOURLY
15.GRBS 7 POINT PROFILE
GRBS MONITORING:
8 AM-130MG/DL
10 AM-132 MG/DL
2 PM-310 MG/DL
4PM-182 MG/DL
8 PM-266 MG/DL
10 pM-198 MG/DL
2 AM-116 MG/DL
AMC BED 3
DAY 4(18/10/22)
S:
Dry cough (increased at night )
HTN+
DM+
FEVER SPIKES +
O:
Patient is conscious, coherent and co-operative
Temp : 101F
BP : 140/70 mmHg
PR : 62 BPM
RR : 26 CPM
GRBS : 132 mg/dl
A:
TYPE 2 DM WITH UNCONTROLLED SUGARS WITH ATYPICAL PNEUMONIA
P:
1.INJ.HAI 6U AT 8 AM ,2PM ,8 PM
2.INJ.NPH 6U AT 8 AM ,8 PM
3.IV FLUIDS @100ML/HR
4.INJ.AUGMENTIN 1.2GM/IV/BD
5.T.AZITHROMYCIN 500MG PO/OD
6.INJ.PAN 40 MG IV/OD
7. INJ.ZOFER 4MG IV SOS
8.INJ.NEOMOL 1GM IV SOS(IF TEMP>101F)
9.T.PCM 650 MG PO/TID
10.SYP.ASCORYL-D 10 ML PO/TID
11.NEB.BUDECORT DUOLIN
12.SYP.BENADRYL 10ML PO/TID
13.T.ULTRACET 1 TAB/PO/BD
14.INJ.PIPTAZ 4.5 GM/IV/BD
15.T. AMLONG 5 MG/PO/OD
16.VITALS,GRBS MONITORING 4TH HOURLY
AMC BED 3
DAY 5 (19/10/22)
S:
Dry cough (decreased compared to yesterday )
HTN+
DM+
FEVER SPIKES +
O:
Patient is conscious, coherent and co-operative
Temp : 100 F
BP : 140/80 mmHg
PR : 98 BPM
RR : 24 CPM
GRBS : 128 mg/dl
A:
TYPE 2 DM WITH ATYPICAL PNEUMONIA
P:
1.INJ.HAI 6U AT 8 AM ,2PM ,8 PM
2.INJ.NPH 6U AT8 AM,8 PM
3.IV FLUIDS @100ML/HR
4.INJ.PIPTAZ 4.5 GM/IV/BD
5.T.AZITHROMYCIN 500MG PO/OD
6.INJ.NEOMOL 1GM IV SOS(IF TEMP>101F)
7.T.PCM 650 MG PO/TID
8.SYP.BENADRYL 10ML PO/TID
9.T.ULTRACET 1 TAB/PO/BD
10.T. AMLONG 5 MG/PO/OD
11.SYP.POTCHLOR 15 ML/PO/TID
12.TUS Q LOZENGES
13.TAB.LIMCEE PO/OD
14.VITALS,GRBS MONITORING 4TH HOURLY
MEDICAL WARD
DAY 6 (20/10/22)
S:
Dry cough (decreased compared to yesterday )
HTN+
DM+
O:
Patient is conscious, coherent and co-operative
Temp : 99.7 F
BP : 140/70 mmHg
PR : 70 BPM
RR : 24 CPM
GRBS : 128 mg/dl
RS:BAE +
CVS:S1S2+
P/A :SOFT,NT
A:
TYPE 2 DM WITH ATYPICAL PNEUMONIA
P:
1.INJ.HAI 6U AT 8 AM ,2PM ,8 PM
2.INJ.NPH 6U AT8 AM,8 PM
3.IV FLUIDS @100ML/HR
4.INJ.NEOMOL 1GM IV SOS(IF TEMP>101F)
5.T.PCM 650 MG PO/TID
6.SYP.BENADRYL 10ML PO/TID
7.T.ULTRACET 1 TAB/PO/BD
8.T.CINOD 10 MG OD
9.SYP.POTCHLOR 15 ML/PO/TID
10.TUS Q LOZENGES
11.TAB.LIMCEE PO/OD
12.VITALS,GRBS MONITORING
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