60F Diabetes 10 days, fever, weakness since 1 day

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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan

I am presemting a case of 60 year old female, house wife resident of addaguduru, came to opd with

Chief complaints:
High grade fever since  6 days, not associated with chills and rigor, complaints of weekness since 2 days. 

History of present illness:
Patient was apparently asymptomatic 5 days back and then she developed fever  high grade , continuous not associated with chills and rigor 
C/o generalized weakness since one day, urinary incontinence, 
So they went to local hospital and got to know that she is having thypoid and increased sugar levels in the body , so they have brought her to kamineni
No c/o nausea , vomitings , no abdominal pain, 
No loose stools no cough cold

Past history:
Known case of dm type 2 since 10 years 
Previously using glimeperide 2 mg,metformin 500 mg
Since thursday glimiperide 1 mg , metformin 500 mg
Not a known case of HTN, CVA,CAD, epilepsy, bleeding diaorder. 
Patient has h/o diabetic retinopathy since 5 years. 

PERSONAL HISTORY: 
Diet - Mixed 
Appetite - Normal 
Sleep -Adequate
No addictions 
No Drug or food allergies. 
Since 2 days decreased appetite
B/b : irregular, constipation+

Family history 
Insignificant. 

GENERAL EXAMINATION
28/8/23
patient is conscious,not coherent, cooperative

 Pallor present

 No Icterus 

No Pedal oedema 

No cyanosis 

No clubbing 

No koilonychia 

No lymphadenopathy

 JVP - Raised 

Bp:110/70 mmhg
Pr : 79 bpm
Rr: 16 cpm
Grbs 520 mg/dl @ 1ml/hr inj HAI
SPO2:98%
Cvs : s1s2 heard no murmurs
Rs : b/l ae+.
P/A: soft non tender
CNS:no findings

Investigations 
28/08/23



30/08/23
31/08/23

PROVISIONAL DIAGNOSIS:
High grade fever

Treatment history:
28/08/23:
Iv fluids NS @100ml/hr
INJ HAI 1 ml +39 ml NS @1 ml/hr
RT feeds water 2nd hourly
BP, RR, PR 2nd hourly
INJ- MONOCEF 1gm IV /BD
31/08/23:
Iv fluids NS @100ml/hr
INJ MONOCEF 1 gm IV /BD 
INJ HAI 1 ml +39 ml NS @1 ml/hr
RT feeds water 2nd hourly
BP, RR, PR 2nd hourly

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