General Medicine

Hii this is E.Bhargavi,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolio.

CASE SHEET

A 55 year old female came to casualty with c/o

Fever since 3 days 

Cough since 3 days 

Difficulty in breathing since 3 days

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 IntactPROVISIONAL 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





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