1702102061 LONG CASE

A 45 old female came to casualty with 

COMPLAINTS OF 
1.Fever since 4 days
2.Vomitings since 4 days
3.Loose stools since 4 days

Patient was apparently asymptomatic 4 days back

1.FEVER
Was low grade,intermittent not associated with chills & rigors, relieved on taking medication, not associated with cough,cold

2.VOMITINGS 
-5 to 6 episodes/day,non bilious non projectile,food/water as content, non blood stained,non foul smelling,

3.LOOSE STOOLS 
-2 to 3/day,watery in consistency, large volume, non foulsmelling, non blood stained, no tensmus 
Associated with pain abdomen at umbilical region

- pt had h/o intermittent high colored urine(she described as red)no h/0 burning micturition

-SOB intermittently since 1 month, on exertion grade 2, not associated with palpitations,chest pain.no h/o orthopnea,paraoxysmal nocturnal dyspnea

C/o pain at right knee joint with restriction of movement.

PAST HISTORY 

Pt was apparently asymptomatic 3 yrs back,then pt had 
- Pain in B/L knee - 3 yrs causing unable to walk properly for which she used to take NSAIDS for severe pain 
- 2 MONTHS BACK:
She slipped from staircase,had fracture of Rt tibia & underwent surgery 1 month back in a hospital in nalgonda & also got diagnosed to be diabetic .since then GRBS : 150MG/dl 

PERSONAL HISTORY 

Diet - Mixed
Appetite - normal
Sleep - Adequate 
Bowel & Bladder movements  - normal
Addictions - Absent 

GENERAL  EXAMINATION 

Pt is conscious, coherent and cooperative .obese 
1.No pallor
2.No icterus
3.No clubbing,cyanosis
4.No koilonychia
5.No lymphadenopathy 
6. Pt had unilateral edema of right leg up to knee with local rise ofctemperature and redness over that region(fractured leg), pus discharge was present at suture site region






VITALS :

1.Temperature - 101f
2. BP - 100/70mmHg
3. PR - 74bpm, normal volume,regular,all peripheral pulses present
4. RR-20cpm
5.spo2- 98% at room air

PER ABDOMEN:

- No distended abdomen
- No abdominal tenderness
- No engorged veins
- Gaurding & rigidity absent

RESPIRATORY SYSTEM:

BAE+ 
NVBS 

CVS :
 S1S2 HEARD 
no thrills no murmurs

CNS
All superficial & deep reflexes are normal 
 
PROVISIONAL DIAGNOSIS:

- Acute Gastroenteritis with DM 2
- ?Candidiasis of oral cavity
- Rt tibia# with ?infected ILMN of tibia

FEVER CHAT :


INVESTIGATIONS 
19/9/21 LFT
19/9/21 BLOOD UREA 
19/9/22  SERUM ELECTROLYTES 
19/9/21  CUE




19/9/21  HEMOGRAM 




HBA1C
RBS
BLOOD UREA
21/9/21  SERUM CREATININE 
21/9/21  SERUM ELECTROLYTES 
21/9/21(12PM)
21/9/21(8AM)
CRP

X ray 


DIAGNOSIS:

- Acute Gastroenteritis with DM 2
- ?Candidiasis of oral cavity
- Rt tibia# with infected ILMN tibia with loosening of implants 


PLAN OF CARE:

1.IVF NS,RL @ 100ML/HR
2 INJ PAN 40MG IV/OD
3.T PCM 650MG PO/SOS
4.INJ ZOFER 4MG/IV/TID
5. INJ NEOMOL 1gm IV/SOS( IF TEMP >101°F)
6.INJ MONOCEF 1gm IV/BD
7.INJ METROGYL 400MG IV/TID
8.INJ HAI ACC TO SLIDING SCALE
9.GRBS 70 PROFILE
10.TAB FLUCONAZOLE 150MG PO/STAT
11.CANDID MOUTH (L/A) PASTE
12.TAB OROFER- XT PO/BD
13.GRBS 70 PROFILE
14.VITALS & TEMPERATURE CHARTING 4TH HRLY
15.PHYSIOTHERAPY

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