A 38 yr old female came to OPD with fever, vomiting and not able to walk..
A 38 yr old female patient sweeper in a fertiliser company by occupation brought to casualilty with fever and vomitings and hypersalivation. She had low grade, intermittent fever which relieves on medication not associated with chills and rigors.
HOPI: She had 5 episodes of vomitings for 2 days which contained food particles, non projectile and non foul smelling. She needed support for walking.
Fever since 3 days, vomitings 5 episodes(12th & 13th June 2022), unable to walk since 2 days
Negative history: no history of shortness of breath, cough, loose stools
Past illness- known hypertensive since 2 years (using medication)
NOT a known case of DM, asthma, tuberculosis, diabetes, asthma, epilepsy, CAD
Personal History: Mixed diet
Bowel And Bladder-Regular
Sleep Adequate
No Allergies And Addictions.
Family History: not significant
General Examination:
Patient is Conscious,
Moderately Built and Nourished.
Pallor Absent
Icterus Absent
Clubbing Absent
Cyanosis Absent
Lymphadenopathy Absent
Edema Absent
Vitals :
Temperature - afebrile
Pulse: 114/min
B.P: 140/80mmHg
SpO2: 98% on RA
GRBS: high
Systemic examination:
ABDOMEN: Palpable liver, no tenderness, distended abdomen.
Lab diagnosis:
Treatment history:
13/6/22
*IVF NS@100ml
*Inj Monocef@1 gm x IV x BD
*Inj Human Actrapid (1ml+39ml NS)@6ml/hr
14/6/22
*IVF 20NS@100ml/hr
D-1 *Injection monocef 2gm×IV×BD
*Injection human actrapid insulin
1ml +39ml NS @ 6ml/hr
*Injection zofer 4mg IV BD
*Injection pan 40mg IV BD
*GRBS 1hourly
*Monitor vitals hourly
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