A 60 Yr male with fever and Alterations in sugar levels

A 60 Year old male with chief complaints of fever since 7 days Alterations in sugar levels since 7days 

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1/11/2022

CASE

This is a case of 60 yr old male who came with the chief complaints of fever since 7 days and Alteration in sugar levels since 7days 

History of present illness 

Patient was apparently asymptomatic 7 days back then he developed raise in temperature which was insidious in onset gradually progressive associated with chills and rigor temperature is aggravated during night and temporarily releived by medication.There is history of fatigue, Burning micturition.No H/O photophobia, decreased vision, pain abdomen, vomitings, loose stools, dark colored stools.No H/O bleeding manifestations.

Past history 

There is H/o Diabetes since 16 years 

No H/O Tuberculosis, Asthma, Hypertension, Epilepsy, Thyroid.

Family history 

There is no significant family history. 

Drug history 

Glimeperide,voglibose & metformin tablets are used.

Personal history 

DIET -Mixed

Appetite-normal

Sleep-adequate

Bowel &bladder -regular

Addiction - no addictions

General examination 

Patient was conscious, coherent, cooperative
No Pallor, Icterus, Clubbing, Cyanosis, Lymphadenopathy
There were no signs of dehydration.

Vitals

Temp: AFebrile 

PR- 73/Min    

RR- 18/Min

BP- 140/90 mmHg

Spo2 -99%at RA

SYSTEMIC EXAMINATION

Per Abdomen - shape of abdomen is obese. No tenderness and no palpable masses are found.

CVS- S1 S2 heard, no murmurs

RS- NVBS.

CNS- NFND

Tone, power and reflexes are normal.

Provisional diagnosis 

Viral pyrexia secondary to dengue with uncontrolled diabetes

Treatment 

Inj pipraz- 4.5gm/iv/BD

Tab Doxycycline 100mg/BD

Tab PCM 650mg/oral/BD

Inj PAN 4mg/Iv/OD

Inj Zofer 4mg/IV

Iv fluids NS@ 75ml/hr

Inj.Neomol 1gm/ml