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





 







Comments

Post a Comment

Popular posts from this blog

A 22 yr old female with generalized weakness and easy fatiguability since 2 months

Image
 A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months  History of Presenting illness Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done Now since 2 months she is complaining of easy fatiguability with generalized weakness  C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III,c/o exertional dyspnea  No c/o chest pain, palpitations, orthopnea,pnd  No c/o fever,loose stools, vomitings PAST HISTORY H/o similar complaints in the past H/o two PRBC transfusion N/k/c/o diabetes HTN TB Asthma Epilepsy thyroid disorders  PERSONAL HISTORY Diet  Mixed Appetite normal Sleep adequate Bowel and bladder  regular Addictions No  Daily routine  Pt wakes up around 7 am takes breakfast and goes for coaching...
Read more

65 year old male with cough since 2 months and fever since 15 days and chest pain since 1 day

Image
 This is 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 available 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 centered  online learning portfolio and your valuable comments on 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. A 65 year old male resident of chityal labourer by occupation came with chief complaints of fever, cough with sputum since 15 days and chest pain from  4pm of  23/06/2023 HISTORY OF PRE...
Read more