50 year old female with fever
THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .
CHIEF COMPLAINTS:
History of fever since 2 weeks with chills , headache , generalised body pains
HOPI:
Patient was apparently asymptomatic 2 weeks back then she developed fever associated with chills, headache ,generalized body pains for which she went to hsptl and was treated conservatively but then fever didn't subside.
Fever is intermittent in nature and associated with chills which is aggravated at night and relieved on medication.
PAST HISTORY:
She is k/c/o DM since 7 years for which she is on OHA
not a k/c/o HTN,CAD,Asthma,TB
PERSONAL HISTORY:
Appetite - Normal
Diet- mixed
Sleep- Adequate
B&B movements - Regular
Addictions - Nil
GENERAL EXAMINATION:
Patient is conscious ,coherent and cooperative and well oriented to time, place and person.
moderately built and nourished
Vitals:
Temperature - 100.2*c
PR :- 80 bpm
RR :-18 cpm
BP :- 110/70 mm Hg
SPO2 :- 98%
GRBS :- 560 mg / dl
No pallor, icterus, cyanosis, clubbing, No Generalised lymphadenopathy, No b/l pedal edema.
SYSTEMIC EXAMINATION:
CVS-S1, S2 heard,no murmurs
Respiratory System:-
BAE- present
NVBS- heard
Per abdomen:-
soft , non tender.
CNS- NAD
INVESTIGATIONS:
TREATMENT:
IVF 0.45 NS @ 50ml/hr
INJ PAN 40 mg/IV/OD
INJ MONOCEF 19m/IV/BD
TAB DOXY100mg PO/BD
TAB DOLO 650 mg PO/TID
INJ HAI S/C TID (8am-1pm-8pm)
PROVISIONAL DIAGNOSIS:
Fever (dengue?)
Uncontrolled diabetes type 2 DM
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