45 Y/ F WITH CAP , ? DENOVO DM TYPE II

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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 

01/12/21

02/12/21

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.

Day 2

01/12/21

S : Intermittent SOB +, Dry cough+, No fever spikes .

O : Pt is conscious,coherent ,cooperative

O/E : 

Temp: 98.5 F 

Bp: 120/80mmhg

Pr: 115 bpm

RR: 45cpm

SPO2: 88% RA

GRBS: 123mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2+

No murmurs 

RS: 

Bilateral wheeze+ in all areas 

 P/A: 

 Soft,Bowel sounds heard .

 

CNS: NAD 

A: Community acquired Pneumonia 

?Atypical pneumonia 

?Denovo Diabetes Mellitus 

P : 

O2 supplementation if spo2<94%

Head end elevation

Continous BIPAP 2nd hrly

Nebulisation with ipravet 8hrly, budicort 12th hrly , salbutamol 6th hrly  

Inj NA 2amp in 50ml NS @ 4ml /hr

Inj hydrocortisone 100mg iv BD - Day1

Inj.Augmentin 1.2gm i.v/BD-Day 3

IVF NS , RL @150ml/hr 

Tab AZITHROMYCIN 500 mg /OD 

Tab.Pan 40mg po/OD. 

Inj. Neomol 1g I.V if temp >101.1F

Inj HAI TID 

Syrup Ascoryl -D 15ml /PO/TID

Inj Deriphylline IV/BD

Tepid sponging 

MONITOR VITALS 2nd hrly

Temp charting 4th hrly

GRBS charting 6th hrly

Day 3 

02/12/21

S : SOB +, Dry cough+, headache,neck pain +

No fever spikes .

O : Pt is conscious,coherent ,cooperative

O/E : 

Temp: Afebrile

Bp: 120/70mmhg

Pr: 116bpm

RR: 45cpm

SPO2: 92% RA

GRBS: 158mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2+

No murmurs 

RS: 

Bilateral wheeze+ in all areas 

Crepts+ in left IAA,IMA,ISA

 P/A: 

 Soft,Bowel sounds heard .

 

CNS: NAD 

A: Community acquired Pneumonia 

?Atypical pneumonia with septic shock

?Denovo Diabetes Mellitus 

P : 

1. O2 supplementation if spo2>94%

2. Head end elevation

3. Continous BIPAP 2nd hrly

4. Nebulisation with ipravet 8hrly, budicort 12th hrly

5. Inj NA 2amp in 50ml NS @ 4ml /hr

6. Inj hydrocortisone 100mg iv BD - Day2

7. Inj.Augmentin 1.2gm i.v/BD-  Day 4

8. IVF NS , RL @150ml/hr 

9. Tab AZITHROMYCIN 500 mg /OD 

10. Tab.Pan 40mg po/OD. 

11. Inj. Neomol 1g I.V if temp >101.1F SOS

12 .Tab Dolo 650mg PO/TID

13. Tab ultracet 1/2 PO qid

14. Inj HAI TID 

15. Syrup Ascoryl -D 15ml /PO/TID

16. Inj Deriphylline IV/BD

17. Tepid sponging 

18. MONITOR VITALS 2nd hrly

19. I/OandTemp charting 4th hrly

20. GRBS charting 6th hrly.

Day-4

3/12/21

S-sob subsided, 

fever spikes -

headache b/l frontal+

Neck pain  +

O-c/c/c

afebrile

PR- 94/min

RR-22min

BP-120/70mmhg 

CVS:s1s2+

R.S:bae +

P/A: obese,bs+

grbs:169mg/dl-6hai

(8pm-226mg/dl-14hai)

A-Community Acquired pneumonia

? ATYPICAL

DENOVO DM2

P-Oxygenation if spo2<92

inj augmentin 1.2gm/iv/bd

neb with budecort ,ipravent

tab azithromycin 500mg/po/od

Tab pcm 650mg po tid

grbs 6th hourly

inj hai s/c tid

bipap intermittently