60 year old female with cough and fever


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November 2 2022

Date of admission:31 October 2022

CHIEF COMPLAINT: patient came to the opd with complaints of fever since 5 days and c/o cough associated with sputum since 5 days 

C/o hoarseness of voice and throat pain since 5 days 

C/o decreased appetite since 5-6 months 

C/o weight loss approximately 20kg over the last 1 year.


HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 5 days back then she got fever and cough associated with sputum. She also had hoarseness of voice and difficulty in swallowing since 5 days.

She had loss weight of 20 kg over 1 year.


PAST HISTORY: Hypertension since 6 months not on regular medication 

Hypothyroidism since 1 year on regular medication

Diabetes mellitus since 6 years on regular glimiperide 1mg , metformin 500mg and saxagliptin 50mg

History of tubectomy 20 years ago.

No history of asthma, tuberculosis


PERSONAL HISTORY:


Married 

Moderately built and nourishment.

Diet: mixed. ( Non vegetarian)

Sleep- normal

Appitite: reduced

Bowel and bladder movements: Regular

Allergy-no 

Addiction- no


FAMILY HISTORY:

Not significant family history.


GENERAL EXAMINATION:

Patient is conscious, coherent, co-operative.

She is well oriented to time, place and person. 

She is moderately built and nourished  

Pallor - absent 

icterus absent

No cyanosis

No clubbing

No edema 

No Lymphadenopathy .


VITALS

Temperature: 98.1 F 

Heart rate : 123 beats /min

Respiratory rate: 22/ min

Blood pressure: 110/ 80 mmHg 

Spo2-94 %

Random blood sugar: 155 mg /dl


SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM

S1, S2 heard 

No murmers 


RESPIRATORY SYSTEM 

Creeps Heard at infrascapular and axillary region 

Wheeze and dyspnea present

Position of trachea: central

Breath sounds: Vesicular

Adventitious sound: bilateral ronchi present 


ABDOMEN 

Shape of abdomen: scaphoid

Non tender

No palpable mass

No free fluids

Spleen and liver not palpable


CENTRAL NERVOUS SYSTEM 

Conscious

Speech: normal

Neck stiffness absent 

ENT examination

Arytenoids: minimal edema

Lingual tonsil hypertrophy

Laryngeal crepitus decreased on left side 





INVESTIGATIONS

Ultrasound report 















PROVISIONAL DIAGNOSIS 

Community acquired pneumonia 

Lower respiratory tract infections with Hypertension , Type 2 Diabetes Mellitus with Hypothyroidism


TREATMENT 

Inj.Agumentin 1.2mg IV/ BD 

Tablet- Azithromycin 500mg PO/ OD 

Tablet - paracetamol 650mg po/ TID 

IVF   NS @ 75ml / hr 

Inj. Pan- D IV / OD 



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