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

On Systemic Examination:

CVS : S1, S2 heard

RS : BAE present

P/A : soft, Non tender

CNS : HMF Intact

Investigations :

Day :1

HEMOGRAM 

Blood grouping and Rh typing

Blood for M.P. strip test

RBS

LFT

Blood urea

Serum creatinine 

Serum electrolytes 

Day :2

Day :3

Day:4

Day :5

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