A 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 .

A 50 year old female who is a housewife and resident of Nalgonda came to OPD with 

CHIEF COMPLAINTS 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

PROVISIONAL DIAGNOSIS:

Uncontrolled sugars

Fever under evaluation (Dengue?)

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)