45 Y/ F with CAP , ? Denovo DM type II

45 yr old female came to casuality with the cheif complaints of

SHORTNESS OF BREATH (Class 2- class 3), according to NYHA CLASSIFICATION.
ASSOCIATED WITH ORTHOPNEA /PND SINCE 15DAYS.

C/O FEVER WITH CHILLS AND RIGORS SINCE 15DAYS.
No diurnal variation.
Subsided on taking medication.

Not a k/c/o HTN, DM, ASTHMA, TB, EPILEPSY, THYROID.

No similar complaints in the past.
No significant family history.

Personal history:
Takes mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements.
No known allergies.
Not an alcoholic.
not a smoker.

O/E:

Pt is c/c/c
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temp:103°f
Bp: 100/80mmhg
Pr:144bpm
RR: 28cpm
SPO2: 97% RA
GRBS: 285mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2+
No murmurs 

RS: DYSPNEA GRADE 4-GRADE 3. 
No wheeze.
Trachea position-central.
Vesicular breath sounds heard

 P/A: 
    Soft , non tender 
    Shape: scaphoid.
    Bowel sounds heard .

CNS: NAD 

Clinical images : 





Provisional diagnosis : 
Community acquired Pneumonia 
?Atypical pneumonia 
?Denovo Diabetes Mellitus 

Investigations : 
29/11/21 



Treatment given : 

O2 supplementation if spo2<90%
Head end elevation upto 30°
Nebulization with IPRAVENT, BUDECORT 2 ampules 8th hrly.
Tab. Dolo 650mg po/TID
Inj.Augmentin 1.25gm i.v/BD
Tab.Pan 40mg po/OD.
Inj. Neomol 100mg I.V if temp >101.1f
MONITOR VITALS 2nd hrly
Temp charting 4th hrly
GRBS charting 4th hrly.

SOAP notes : 
Day 1 
30/11/21 

S : Fever spike + 
SOB + 

O : Pt is conscious,coherent ,cooperative

O/E : 
Temp: 98.5 F 
Bp: 100/ 70mmhg
Pr: 120 bpm
RR: 24 cpm
SPO2: 87 % RA
GRBS: 268 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2+
No murmurs 

RS: 
DYSPNEA GRADE 4-GRADE 3. 
No wheeze.
Trachea position-central.
Vesicular breath sounds heard

 P/A: 
 Soft, non tender 
 Shape: scaphoid.
 Bowel sounds heard .
 
CNS: NAD 

A: Community acquired Pneumonia 
?Atypical pneumonia 
?Denovo Diabetes Mellitus 

P : 
O2 supplementation if spo2<90%
Head end elevation upto 30°
Nebulization with IPRAVENT, BUDECORT 2 ampules 8th hrly.
Tab. Dolo 650mg po/TID
Inj.Augmentin 1.25gm i.v/BD
Tab AZITHROMYCIN 500 mg /OD 
Tab.Pan 40mg po/OD.
Inj. Neomol 100mg I.V if temp >101.1f
MONITOR VITALS 2nd hrly
Temp charting 4th hrly
GRBS charting 4th hrly.

Comments

Post a Comment

Popular Posts