60 year old female with fever

 This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. 

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION

60 year old female came with the complaints of Fever since 4 days 

Vomiting since 2 days

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 4 days back, then she developed fever which is high garde, intermittent, relieved with medication which is associated with body pains, generalised weakness and headache

No h/o pain abdomen, burning micturition, diarrhoea

No h/o cough, cold

H/o vomiting since 2 days non bilious, non blood stained, non projectile, food particles as content

No h/o outside food consumption

PAST HISTORY:

K/c/o DM type 2 since 20.years(on OHA in afternoon and 15U MIXTARD insulin BD since 10 days)

K/c/o HTN since 20 years (T. AMLONG 5mg+ T. ATENOLOL 50 mg)

N/k/c/o CVA, CAD, epilepsy, TB, Asthma

PERSONAL HISTORY:

Takes mixed diet, normal appetite

Has constipation since 4 days, flatus passed

Addictions: occasional drinker, doesnot smoke

O/E: 

Patient is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema

Vitals:

Temp: 98.2F

BP: 140/80mm hg

PR: 82 bpm

Spo2: 96% at RA

GRBS: 350 mg/dl

CVS: S1 S2 heard

RS: BAE present

P/A: soft, non tender, bowel sounds heard

CNS: 

Investigations:

FBS-101mg/dl

HBA1C-7.2%

PLBS- 205 mg/dl

DIAGNOSIS:

Uncontrolled sugars with Pyrexia under evaluation

TREATMENT:

IV FLUIDS- NS AT 75 ml/hr

Inj. MONOCEF 1gm IV/BD

Inj. NEOMOL 1gm IV/SOS

Inj. OPTINEURON in 100ml NS IV/OD

INJ. PAN 40 IV/OD

INJ. ZOFER 4mg IV /SOS

INJ. HAI accordingly

INJ. NPH according

Tab. PCM 650mg PO/SOS

Tab. ATENOLOL 50mg+ Tab. AMOLODIPINE 5mg PO/OD

Syp. LACTULOSE 15ml PO/HS