A 65 year old male patient, resident of Thurkapallem, shop keeper by occupation came to the OPD with chief complaints of
Chief Complaints:
Fever since 6 days
Breathlessness since 3 days
History of Presenting Illness:
Patient was apparently asymptomatic 6 days back, then he developed cold and cough with expectorant (green, mucoid) which has now subsided.
He developed fever since 6 days, high grade, continuous and not associated with chills and rigour. Relieved on taking medications prescribed by local RMP.
Complaints of decreased appetite since 4 days.
Shortness of breath since 3 days - Grade 2
No history of hemoptysis
No history of tightness in chest
No history of decreased urine output, pedal edema, lose stools
Past History:
Not Known Case Of HTN, DBM, Thyroid, Epilepsy
Previous Surgical History Right Tibial Fracture 5 years ago
History of taking NSAIDS for pain in both knee joints.
Personal History:
Diet: Mixed
Appetite: Nil
Bowel and Bladder Movements: Normal
Addictions: Used to smoke 2 packs/ day but stopped 5 years ago
Family History:
No similar complaints
Dietary History:
6:00 am - Cup of tea with sugar
7:30 am - Breakfast
9:00 am - Cup of tea with sugar
12:30 pm- Lunch (Rice)
4:30 pm - (Rice)
6:00 pm - Cup of tea with sugar
7:30 pm - Dinner ( Rice)
General Examination:
Patient is conscious, coherent, co-operative
Moderately built and nourished
Pallor present
No Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.
Vitals:
PR: 118 bpm
RR: 21 cpm
BP: 90/60 mmhg
Temp: 102*
SpO2: 96%
GRBS: High
Systemic Examination:
CVS: S1 S2 heard, no murmurs detected
Respiratory:
Inspection:
normal chest shape,
position of trachea - central
No scars,sinuses,engorged veins
Abdominothoracic type of respiration
NVBS
decreased breath sounds in infra axillary and mammary area
Dysnea, wheeze, rales and ronchi - absent
Palpation :- all inspectory findings are confirmed on palpation.
Percussion:- right left
Infraclavicular resonant resonant
Mammary dullnote. resonant
Axillary. resonant resonant
Infraaxillary. dullnote. resonant
Suprascapular. resonant. resonant
Infrascapular. dullnote resonant
Upper, mid, lower. resonant. resonant
Auscultation :-
normal vesicular breath sounds heard
decreased breath sounds in right infra mammary, infra axillary, infra scapular areas.
Per Abdomen:
scaphoid shaped, soft and diffuse tenderness
CNS:
Drowsy, rousable
Slurred Speech
No Neck Stiffness
Tone: Normal in both limbs
Power: 4/5 in both limbs
Reflexes: Right Left
Biceps ++ ++
Triceps ++ ++
Supinator +. +
Knee ++. ++
Ankle ++. ++
Plantar Flexor Flexor
Provisional Diagnosis:
Diabetic Ketoacidosis 2* to respiratory disease
Investigations:
Treatment:
2/12/2023
1) NBM until further orders
2) IV Fluids NS @ 100ml/hr
3) Inj. PIPTAZ 2.5gm IV/TID
4) Inj. LINEZOLID 600mg IV/BD
5) Tab. AZITHROMYCIN 500mg OD
6) Tab. FLUCONAZOLE 150 mg OD
7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr
8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)
9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
10) IV Fluids - FRUSIDEX @ 50ml/hr
11) Tab. ATORUAS 40mg OD
12) Tab. CLOPITAB - A75/75 OD
13) Inj. PAN 40mg IV/OD
14) GRBS moniter hourly
15) Moniter BP, PR, RR, SPO2 Hourly
8:40 PM
1) Stop insulin infusion
2) Inj. HAI 6U in 500ml DNS over 5hrs
3) Inj. KCL 20mEq in 500 NS over 5hrs
Followed by
4) Inj. KCL 20mEq in 500 NS over 5hrs
5) GRBS moniter hourly
3/12/2023
1) Inj. PIPTAZ 2.25gm IV/TID
2) Inj. LINEZOLID 600mg IV/BD
3) Tab. AZITHROMYCIN 500mg OD
4) Tab. FLUCONAZOLE 150 mg OD
5) Inj. PAN 40mg IV/OD
6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)
7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
8) Inj. HOMAN ACTRAPID INSULIN infusion S/L TID according to GRBS
9) Tab. ATORUAS 40mg OD
10) Tab. CLOPITAB - A75/75 OD
11) GRBS moniter 2 hourly
12) Moniter BP, PR, RR, SPO2 2 Hourly
13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly
14) Inj. KCL 20mEq in 500 NS over 5hrs
15) Tab. FENOFIBRATE 160mg OD
16) Tab. METOPROLOL 25mg OD
17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr
4/12/23
1) Calcium gluconate 1 amp iv stat
2) inj 25% dextrose + 10 IU actrapid iv stat
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