patient with fever cough and sob

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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.

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