60F Diabetes 10 days, fever, weakness since 1 day
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31/08/23
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
PROVISIONAL DIAGNOSIS:
High grade fever
Treatment history:
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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