60 yr old female with uncontrolled sugars
A 60 yr old female patient occupationaly housewife came to casualty on 01/12/2020 at 5: 30 pm with complaints of chest pain since 4 days pricking type radiating to back relived on medication, no aggravating and relieving factorsGRBS at time of presenting is 585
Burning type of epigastric pain since 3 days
No radiation, no aggravating and relieving factors
Relived on inj .pan 40 mg stat
Complaints of constipation since 3 days
No complaints of abdominal pain and abdominal distenstion
No history palpitations, profuse sweating
No complaints of shortness of breath ,orthopnea PND
No history of fever cold cough
No history diarrhoea
Known case of hypertension since 2 yrs ( unknown medication)
DM 2 since 2 years ( unknown medication)
1½ year back patient has fever for 3 days with altered sensorium for 1 day and shortness of breath for 1 day.
Diagnosed as acute kidney injury with septic shock with dyselectrolytemia
History of 1 episode of seizuers
Not a known case of epilepsy, tb,asthma, CVA,CAD.
Personal history:
Appetite: normal
Bowels: irregular
Bladder- normal micturition
Family history:
No history of DM, HTN CAD, CVA, asthma in the family
General examination: patient is conscious, coherent, cooperative
Pallor is seen.
No icterus, cyanosis, clubbing,lymphadenopathy, edema
Vitals:
Temperature: 98.9F
Pulse: 80bpm
Respiratory rate: 19/ min
Bp: 110/60mm hg
Spo2: 98% at RA
GRBS: 87 mg%
Systemic examination:
Cvs: S1 S2 heard no additional sounds or murmurs
Rs: NVBS
Abdomen: soft,non tender
Cns: higher mental functions
Provisional diagnosis Right upper lobe pneumonia, right upperlobe consolidation with sepsis, with uncontrolled type 2 diabetes mellitus.
INVESTIGATIONS:
Complet urine examination
ABG
Rtpcr
Hrct chest
TREATMENT GIVEN ON 01/12/2020
1. IVF 1 NS @125 ML/HR
2. NBM TILL FURTHER ORDERS
3. GRBS MONITORING
4. INJ PAN 40 MG IV BD
5. INJ OPTINEURON 1 AMP IN 100 ML
6. BP,PR,SPO2 ,RR MONITORING
7. STRICT I/O CHARTING
8. 2 TO 3 EGG WHITES/ DAY
7.2 SCOOPS OF PROTEIN POWDER IN 100 ML OF MILK TID
8. INJ MONOCEF IG IV BD.
Treatment given on 02/12/2020
1.IVF 1 NS @100 ML/HR
2.INJ.MONOCEF IG IV BD
3.INJ PAN 40 MG IV BD
4. INJ ZOFER 4 MG IV SOS
5.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
6. 2 - 3 EGG WHITES/ DAY
7. 2 SCOOPS OF PROTEIN POWDER IN 200ML OF MILK TID
8.GRBS MONITORING 2 ND HOURLY
9.BP,PR,SPO2,RR,TEMPERATURE MONITORING
TREATMENT GIVEN ON 03/10/2020
1.IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .HUMAN ACTRAPID INSULIN S/C TID ACCORDING TO SLIDING SCALE
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. 2 - 3 EGG WHITES PER DAY
9. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
10. GRBS MONITORING 2ND HRLY
11 . BP. PR SPO2 TEMPERATURE MONITORING 2 HRL
12. TAB ULTRACET BD PO
13. SOFT ORAL FEEDS TO BE ADOPTED
14. STRICTLY DIABETIC DIET
TREATMENT GIVEN ON 04 /12/2020
1. IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .HUMAN ACTRAPID INSULIN S/C TID
8AM 2PM 8PM
NPH 10 U 10U
REGULAR 12U 12U 12U
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. INJ TRAMADOL 50 MG IN 100 ML IN NS IV OD
9. 2 - 3 EGG WHITES PER DAY
10. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
11. SOFT ORAL FEEDS TO BE ADOPTED
12. STRICTLY DIABETIC DIET
13. SYRUP LACTULOSE 10 ML PO TID
14 . SYRUP ASCORIL P 5 ML PO TID
15. NEBULISATION 2 REGULAR MUCOMIST 12 HRLY.
TREATMENT GIVEN ON 05/12/2020
1. IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .HUMAN ACTRAPID INSULIN S/C TID
8AM 2PM 8PM
NPH 16 U 16U
REGULAR 14U 14U 14U
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. INJ TRAMADOL 50 MG IN 100 ML IN NS IV OD
9. 2 - 3 EGG WHITES PER DAY
10. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
11. STRICTLY DIABETIC DIET
12. SYRUP LACTULOSE 10 ML PO TID
13 . SYRUP ASCORIL P 5 ML PO TID
14. NEBULISATION 2 REGULAR MUCOMIST 12 HRLY.
TREATMENT GIVEN ON 06/12/2020
1. IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .HUMAN ACTRAPID INSULIN S/C TID
8AM 2PM 8PM
NPH 16 U 16U
REGULAR 14U 14U 14U
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. INJ TRAMADOL 50 MG IN 100 ML IN NS IV OD
9. 2 - 3 EGG WHITES PER DAY
10. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
11. STRICTLY DIABETIC DIET
12 . SYRUP ASCORIL P 5 ML PO TID
13. NEBULISATION 2 REGULAR MUCOMIST 12 HRLY.
TREATMENT GIVEN ON 07/12/2020
1. IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .NPH ACTRAPID INSULIN S/C TID
8AM 2PM 8PM
NPH 16 U 16U
REGULAR 14U 14U 14U
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. INJ TRAMADOL 50 MG IN 100 ML IN NS IV OD
9. 2 - 3 EGG WHITES PER DAY
10. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
11. STRICTLY DIABETIC DIET
12 . SYRUP ASCORIL P 5 ML PO TID
13. NEBULISATION 2 REGULAR MUCOMIST 12 HRLY.
TREATMENT GIVEN ON 08/10/2020
1. IVF 1 NS @ 100ML / HR
2. INJ PIPTAZ 3.375 IV TID
3. CLARITHROMYCIN 500 MG PO BD
4. INJ .NPH ACTRAPID INSULIN S/C TID
8AM 2PM 8PM
NPH 12U 12U
REGULAR 10U 10U 10U
5. INJ PAN 40 MG IV OD
6. INJ ZOFER 4 MG IV SOS
7.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD
8. INJ TRAMADOL 50 MG IN 100 ML IN NS IV OD
9. 2 - 3 EGG WHITES PER DAY
10. 2 SCOOPS OF PROTEIN POWDER IN 200 ML OF MILK TID
11. STRICTLY DIABETIC DIET
12 . SYRUP ASCORIL P 7.5 ML PO TID
13. NEBULISATION 2 REGULAR MUCOMIST 12 HRLY.
