A case of 55 year old female with fever and generalized body pains

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Chief complaints:-

Patient came with the chief complaints of fever since 5 days,mild cough since 4 days and shortness of breath since 4 days associated with pain abdomen,low backache and body pains and discharge of pus from the external fixator site since 5 days

History of present illness:-

Patient was apparently asymptomatic 5 days back and then she developed fever which was high grade and relieved on medication not associated with chills and rigor.then she developed shortness of breath and mild cough since 4 days .shortness of breath was present even during rest which is grade 4 SOB .patient also presented with pain abdomen  and low backache,and  also discharge of pus from the external fixator site associated with pain.

Past history:-

She had history of road traffic accident 3 months back,which lead to fracture of left leg ,which was treated by wound debridement and application of external fixator.

She is a known case of diabetes.

Actually she was first treated for fever by an RMP 5 days back which was relieved but then she again developed fever and shortness of breath, was reffered to this hospital 

No history of syphilis,no tuberculosis, no thyroid abnormalities,no asthma,no COPD.

No similar complaints in past

Personal history:-

Appetite normal,mixed diet,regular bowel and bladder movements,no addictions.

Family history:-

No significant family history.

General examination

Patient was conscious, coherent , cooperative,well oriented to time ,place,person.

No pallor,no icterus,no cyanosis,no lymphadenopathy,no clubbing of fingers.

Temperature:- on admission i.e on 26-01-2022 it was 97.6 F,on 27-01-2022 at 2 pm her temperature was 98.2 F.

Pulse rate:-on admission on 26-01-2022 at 10pm it was 128,on 27-01-2022 it was around 84 

BP:-on admission 110/70,on 27-01-2022 it is 100/60

Respiratory rate :- on admission 20cpm,later at 5pm on 27-01-2022 it was around 25cpm.

GRBS:-237 mg/dl on admission,155 mg/dl on 27-01-2022 

Systemic examination:-

Cvs:- S1 and S2 heard

Respiratory system:- dyspnea persent,central trachea,vesicular breath sounds are heard.

Abdomen:- 

 abdomen is distended, tenderness is present over the upper right abdomen,no palpable mass is seen,right flank is full compared to left.liver is not palpable,spleen is not palpable,bowel sounds are present.

CNS examination:-

No focal neurological deficits present.

Investigations:-

27-01-22

28-01-22

Provisional diagnosis:- diabetic keto acidosis .

Management:-