58/F with uncontrolled sugar and fever

 

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A 58year old woman who works in an Anganwadi center came from Gurrampur with complaints of fever, generalised body pains since 20days

History of presenting illness 

She was apparently asymptomatic 7 years back, then she had generalised weakness and went to a hospital was diagnosed with diabetes and was started on medication(GLIMIPERIDE and METFORMIN)

She has fever, high grade with evening rise in temperature and with chills. She also has generalised bodypains.

Then she went to a hospital and found she has high sugars and was told to get admitted but patient didnot and came home and went to a local doctor and was given medication(unknown)

But the fever didnot subside and came to our hospital

Past history 

She is not a known case of hypertension, asthma, epilepsy, CAD, Thyroid disorders 

H/o dust allergy and not allergic to any medicines 

Personal history 

She has normal appetite, takes mixed diet, sleep is adequate, bowel and bladder movements are regular

She takes alcohol occasionally since 8years

She chews tobacco daily since 1year

Daily routine 

She wakes up at 6am and helps her daughter in house chores(washes utensils) have breakfast, gets ready to work(Anganwadi center) and comes home for lunch at 1pm and again return to work at reaches home by 3pm and again in the she helps in house chores and have her dinner at 8pm 

and sleep at 9pm

General examination

Patient is conscious, coherent and cooperative 

She is moderately built and moderately nourished

She has pallor 

No icterus, cyanosis, clubbing, lymphadenopathy, edema 

Vitals

Temperature afebrile

Pulse rate 93bpm

Blood pressure 100/70mmHg

Respiratory rate 18cpm

GRBS 305mg/dl

Systemic examination 

PER ABDOMEN 

Inspection: 

No Abdominal distension 

No scars, sinuses, mass visible

Palpation:

Inspectory findings are confirmed 

No local rise of temperature

Tenderness 

Auscultation

Normal bowel sounds heard

RESPIRATORY SYSTEM EXAMINATION

Inspection:

Bilaterally Symmetrical chest movements present 

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Percussion: 

Resonant note present in all lung areas

Auscultation:

Normal vesicular breath sounds heard. 

CARDIOVASCULAR SYSTEM EXAMINATION 

Inspection : Bilaterally symmetrical chest present 

No scars, sinuses

Palpation:

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard, no murmurs or additional heart sounds

CENTRAL NERVOUS SYSTEM EXAMINATION 

Higher mental functions intact 

Cranial nerves intact 

No focal neurological defecits

Provisional diagnosis

Viral pyrexia with uncontrolled sugars

Investigations 

GRBS

14/8/2022

8am 254mg/dl

2pm 343mg/dl

8pm 337mg/dl

15/8/2022

8am 89mg/dl

2pm 147mg/dl

8pm 137mg/dl

16/8/2022

8am 197mg/dl

2pm 305mg/dl

Treatment 

IV fluids NS RL @50ml/hr

Inj.MONOCEF 1gm IV BD

Inj.PAN 40mg IV OD

Inj.NEOMOL 1gm IV(if required)

Inj. HAI 6-6-6units SC TID

Inj. NPH 10-8units SC BD

Tab. DOLO 650mg PO TID

Tab. DOXY 100mg PO BD