70 year old female with diabetic ketosis(resolved) with ?enteric fever with UTI with type 2 DM with HTN

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Here is a case i have seen:

70 yr old female came with c/o fever associated with chills since yesterday morning.

She was apparently asymptomatic till yesterday morning.at 6 am pt. had one spike of fever associated with chills,high grade fever,relieved on taking medication with severe sweating.Again she had another spike of fever at 8 pm in the evening associated with chills,so they took her to near by hospital,there BP was recorded as SBP-230 and taken nifedipine sublingually(dose unknown).Again today at 9:30 pm pt. had one episode of fever spike associated with chills and relieved on medication.not associated with nausea,vomitings.no c/o headache, giddiness,loc.no h/o bleeding manifestations(hematuria,malena),no h/o retrobulbar pain.no h/o palpitations,chest pain,syncopal attack,dizziness, dyspnea.no c/o burning micturition.no h/o constipation, diarrhoea.

K/c/o DM since 20 yrs.

K/c/o HTN since 20 yrs.

Not on regular medication

H/o hysterectomy 30 yrs back.

She takes mixed diet

Adequate sleep 

Bowel and bladder movements regular

O/E: pt is c/c/c

Pallor present

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal edema

Temp:101.1F

PR:104bpm

BP:110/50 mmhg

RR-21cpm

Spo2-98%

GRBS-357mg/dl

CVS-s1,s2 heard.

RS-b/l air entry present,NVBS heard

CNS- Higher mental functions intact

         motor system normal

         Sensory system normal

         Cranial nerves intact

P/A-soft,non tender.

Investigations:

CBP-

   Hb:8.4

   TLC:11,000

   Plt:1.0

RFT-

  Urea:50

  Creat:1.2

  Uric acid:4.0

   Na:126

   K-4.6

   Cl-95

Ketone bodies: positive

LFT-

  TB:1.23

   DB:0.67

   AST:24

   ALT:21

   ALP:187

   TP:4.6

   A/G ratio:2.0

CUE:

Appearance -clear

Albumin++

Sugar+++

Pus cells :5 to 6

Ecg-

            

           

CXR-

       

Usg abdomen-

            

Treatment given:

IVF-1 unit NS at 100ml/hr

Oral soft diet

Inj.pcm 1gm iv stat if temp. more than 101F

Temp. Charting 4th hrly

Tepid sponging

Iv HAI 6u stat

Inj.HAI 0.05ml /kg/hr iv @3ml per hr

GRBS charting 1 hrly

Bp,PR,temp charting 4th hrly

Strict  input /output charting

Inj.augmentin 1.2gm iv BD

Inj.pantop 40mg iv od

Tab. Neurobion forte po od

Tab.pcm650mg  po tid 

Day 2:

O/E: pt is c/c/c

Temp:101.1F

PR:82bpm

BP:110/70 mmhg

RR-20cpm

Spo2-98%

GRBS-129mg/dl

I/o-1200/600ml

CVS-s1,s2 heard.

RS-b/l air entry present,NVBS heard

CNS- Higher mental functions intact

         motor system normal

         Sensory system normal

         Cranial nerves intact

P/A-soft,non tender.

Hb-8.4

TLC-11,000

Plt.-1.0

FBS-189mg/dl

HbA1c-7.2

Na-127

K -4.3

Cl-94

NS1 Ag-negative

Retic count-1.2

             

       

       

2decho-

     

         

Treatment

Inj.pcm 1gm iv stat if temp. more than 101F

Temp. Charting 4th hrly

GRBS charting 4th hrly

Bp,PR,temp charting 4th hrly

Strict  input /output charting

Inj.augmentin 1.2gm iv BD

Inj.pantop 40mg iv od

Tab. Neurobion forte po od

Tab.pcm650mg  po tid 

Inj.HAI 0.05ml /kg/hr @3ml per hr

Inj.falcigo 120mg iv stat(0,12,24,48hrs)

Day 3

C/o two fever spikes(101F,102F)

O/e : pt. C/C/C
          Temp:98.7F
          PR:128bpm
          BP:140/60mmhg

           RR-16cpm

           I/O:1700/1200
          Grbs:211mg/dl @8 am
          CVS:S1,S2 heard
           RS:BAE +
      P/A -soft,non tender
      CNS-intact

Hb-8.5

TLC-11,000

Plt-90,000

Urine for ketone bodies-negative

Na-131

K -4.3

Cl-98

PT-20sec

INR-1.4

APTT-39sec

BT-2min 

CT-4min 30sec

            

      

Treatment

Inj.pcm 1gm iv stat if temp. more than 101F

Temp. Charting 4th hrly

GRBS charting 4th hrly

Bp,PR,temp charting 4th hrly

Strict  input /output charting

Inj. Ceftriaxone 1 gm iv BD

Inj.pantop 40mg iv od

Tab. Neurobion forte po od

Tab.pcm650mg  po tid 

Inj HAI sc acc. to GRBS

Tab.olmesartan 40mg po od

Day 4

C/o one fever spike.

O/e : pt. C/C/C
          Temp:99.2F
          PR:94bpm
          BP:160/90mmhg
          I/O:1300/1100
          Grbs:197mg/dl @8 am
          CVS:S1,S2 heard
           RS:BAE +,fine crepts in ISA,IAA(rt.side more than left side)
      P/A -soft,non tender
      CNS-intact

Hb-7.4

TLC-8,600

Plt-1.0

Na-133

K -3.7

Cl-98

CXR-

         

Treatment

Inj.pcm 1gm iv stat if temp. more than 101F

Temp. Charting 4th hrly

GRBS charting 4th hrly

Bp,PR,temp charting 4th hrly

Strict  input /output charting

Inj. Ceftriaxone 1 gm iv BD

Inj.pantop 40mg iv od

Tab. Neurobion forte po od

Tab.pcm650mg  po tid 

Tab. Glimi M2 po 0D

Tab.olmesartan 40mg po od

Day 5

C/o one fever spike at night.
O/e : pt. C/C/C
          Temp:98.6F
          PR:98bpm
          BP:140/60mmhg
          I/O:1600/1200
          Grbs:257mg/dl @8 am
          CVS:S1,S2 heard
           RS:BAE +,fine crepts in ISA,IAA(rt.side more than left side)
      P/A -soft,non tender
      CNS-intact

Hb-7.9

TLC-8,500

Plt.-1.50

Treatment

Inj.pcm 1gm iv stat if temp. more than 101F

Temp. Charting 4th hrly

GRBS charting 4th hrly

Bp,PR,temp charting 4th hrly

Strict  input /output charting

Inj. Ceftriaxone 1 gm iv BD

Inj.pantop 40mg iv od

Tab. Neurobion forte po od

Tab.pcm650mg  po tid 

Tab.olmesartan 40mg po od

Tab.Glimi M2 po od at 8am

Tab. Metformin 500mg po od at 8pm