? FEVER UNDER EVALUATIONUNCONTROLLED SUGARS (DENOVO DM)K/C/O HTN SINCE 5 YEARS
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 65 year old female , who was agricultural labourer came to the casuality with chief complaints of
- FEVER since 4 days
- SHORTNESS OF BREATH since 4 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 days back then she developed fever which was high grade associated with chills and rigor,present through out the day , with no diurnal variation and fever relieved on taking medications.
Fever was not associated with rash, nausea, vomiting, malena and pain abdomen
C/o shortness of breath (initially grade 2 and then gradually progressed to grade 3) according to NYHA classification.
For the above complaints she was taken to a nearby RMP and was diagnosed with Denovo-DM and was put on medication (Voglife-GM1) and was referred to KIMS
PAST HISTORY:
She was a k/c/o HTN since 5 years and was on regular medication (TELMIKIND 40)
Not a k/c/o TB,Asthama, CAD/CVA ,Thyroid and epilepsy
She underwent tubectomy 23 years back
PERSONAL HISTORY:
Mixed diet
Sleep adequate
Appetite - normal
Bowel and bladder movements regular
No addictions
GENERAL EXAMINATION :
- Patient is conscious, coherent, co-operative.
Moderately built and moderately nourished
- No pallor, cyanosis, clubbing,icterus koilonychia, lymphadenopathy and edema
VITALS:
Temperature- Afebrile
Pulse rate- 86 bpm
Respiratory Rate- 24 cpm
BP-150/100 mmHg
SPO2 at room air- 98%
GRBS 405 mg/dl
SYSTEMIC EXAMINATION:
CVS
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is soft and non tender.
No organomegaly.
Bowel sounds heard.
CNS:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
PROVISIONAL DIAGNOSIS:
? DIABETIC KETOACIDOSIS
INVESTIGATIONS
On day 15/08/2021
CXR
ECG
HEMOGRAM
CUE
URINE FOR KETONE BODIES
Negative
ABG
SERUM ELECTROLYTES
SERUM CREATININE
0.9 mg/dl
BLOOD UREA
40 mg/dl
LFT
HBA1C
7.6 %
RBS
459 mg/dl
DENGUE NS1 ANTIGEN
Negative
BLOOD PARASITES (M.P)
Negative
HIV 1/2 RAPID TEST
Non reactive
USG ABDOMEN
PROVISIONAL DIAGNOSIS
? FEVER UNDER EVALUATION
UNCONTROLLED SUGARS (DENOVO DM)
K/C/O HTN SINCE 5 YEARS
TREATMENT :
Day 1
1. IV Fluids (NS) 100ml/hr
2. Inj. HAI infusion acc to algorithm 1
3. Inj Pantop 40mg iv od
4. GRBS charting hourly
5. I/O charting
6. Tab DOLO 650mg/PO/TID
7. Inj NEOMAL 100ml/IV
8. Inj MONOCEF 1gm/IV/BD
