A 65 year old woman presented with fever associated with chills and rigor

August 22,2022
Hi , Iam Princy rose ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios.

CASE SHEET:

Chief complaints:
Fever associated with chills and rigor since one week with high grade fever . 
Difficulty in walking since 3 days
Bilateral lower limb weakness 3 days
Diagnosed with Type 2 diabetes mellitus since 10 years 




HISTORY OF PRESENT ILLNESS:

Since one week she's having high grade fever with chills and rigors after that she complaint of decreased food intake and she missed OHAs since 2 days .c/o difficulty in walking and bilateral lower limb weakness.
C/o passage of urine and stools in clothes due to weakness in lower limbs since two days 









ASSOCIATED DISEASES:
Type 2 diabetes mellitus 
Hyperthyroidism




PAST HISTORY:
Is a k/c/o diabetes mellitus on OHAs since 10 years 
K/c/o hyperthyroidism on T.neomercazole since 20 years 
Is not a k/c/o HTN/Asthma/CAD/Epilepsy 


PERSONAL HISTORY:

Nil

FAMILY HISTORY:
Nil


DRUG HISTORY:



GENERAL EXAMINATION:
>Pallor : no

>Icterus :no 

>Cyanosis : no 

>Clubbing : no 

>Lymphadenopathy : no


>Edema : no 


(Pic upload)

VITALS:
Temperature: 98.6

Pulse: 82 beats per minute

Respiratory rate: 16cycles per minute

Blood pressure: 120/80mm of Hg

SPO2: 98%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid 
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: Normal 

INVESTIGATIONS:
Biochemical investigations:
   
Treatment

PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis
 


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