55 year old presenting with fever,sob

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

55 year old female came with chief complaints of 

• Fever since 4 days

• SOB since 4 days

HOPI:  The patient was apparently asymptomatic 4 days back , then developed  she had a H/o RTA ( Fracture of left lowerlimb) S/p wound debridement with external fixator under spinal anaesthesia)

H/o pus discharge from external fixator site.

Grade 4 SOB progressive in nature ( At rest) a/w lower back ache and generalised body pains.

 , progressive in nature

, high grade , relieved on medication.

PAST HISTORY:  k/c/o Diabetes mellitus 2

Not a K/c/o HTN, TB,CVA ,CAD ,Epilepsy ,Asthma

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

B&B: Regular 

Addictions: No addictions.

O/E

General examination 

Temp: 98.9 F

PR: 100 bpm

BP: 130/90 mm hg

RR:  22 cpm

SpO2: 98% @ RA

GRBS: 387 mg / dl

Systemic examination 

CVS: S1S2 + , No murmurs

RS: BAE + , NVBS

P/A: Soft , NT

CNS:  No FND

INVESTIGATIONS

TREATMENT:

IVF NS & RL continuous infusion @ 180 ml/hr

Inj. HAI 8 units/IV/STAT

Inj. HAI 10 ml in 39 ml NS IV @ 6ml/hr

Inj. MEROPENEM 1gm IV/BD

Inj. VANCOMYCIN 1 gm in 100 ml NS IV/BD

Inj. PAN 40mg IV/OD

GRBS Monitoring hourly 

IVF 25% Dextrose if GRBS is more than 150 mg/dl.