A 45 year old female patient presented with chief complaints of fever and shortness of breath

 A 45 year old female patient resident of Chinthapally who is a agricultural labourer by occupation came with chief complaints of shortness of breath and fever since 15 days 

HOPI 

Patient was apparently asymptomatic 15 days back.

Then she developed fever since 15 days associated with chills .She also has shortness of breath since 15 days.

15 days ago she had fever for which she went to the local hospital and got treated. After the treatment the fever subsided and she developed fever again for  which she went to the local hospital where she was diagnosed with thrombocytopenia.Then they came to Kims 3 days ago for the treatment of thrombocytopenia.

No history of nausea vomiting.

Past history :No history of Hypertension, tuberculosis, asthma.

Personal history

Diet:mixed 

appetite : normal

Bowel and bladder: regular

Sleep : adequate

Addictions:no addiction

Family history:no relevant family history

General examination:

Patient is conscious, coherent and non-cooperative.

Moderately built and nourished

Pallor: absent 

Icterus: absent

Cyanosis:absent 

Clubbing: absent

Lymphadenopathy:absent

Odema : absent 

Vitals 

Temperature:afebrile 

Respiratory rate:24 cycles/min 

Pulse rate:120 beats per min 

BP:100/70 mm Hg

Systemic examination

Respiratory system: bilateral air entry present.Wheezing is absent

Cardiovascular system:S1,S2 heard 

CNS :No focal neurological defect 

Perabdomen : non tender, soft

  Umbilicus: central 

 *CLINICAL IMAGES







PROVISIONAL DIAGNOSIS: community acquired pneumonia.
Denovo Diabetes mellitus

*INVESTIGATIONS

CHEST Xray



ECG

Hemogram




*Treatment:

D2 supplementation if Spo2 <90%

Head elevation upto 30°

Inj.Augmentin 1.2 gm IV BD 

Nebulizers PRAVENT ,BUDECORT  2 resipules 8 hourly

Tab. Dolo 650mg po/TID

Tab.pan 40mg po/OD.

Inj. Neomol 100mg I.V if temp >101.1f





 







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