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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