case history -5

 

A 60 yr old female with fever and productive cough

Hello, I am kamuni prudvipriya 3rd year dental student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

A 60yr old female came with
CHIEF COMPLAINTS:
- fever since 10 days
-productive  cough since 10 days
-vomitings since 10days

HOPI:
Patient was aparently asymptomatic 10 days back.She then developed fever low grade,intermittent ,not associated with chills and rigors ,relieved on medications
C/o cough with expectoration since 10 days ,whitish mucoid sputum not blood tinged
C/o nausea and vomitings since 10days 2- 3 episodes per day which is watery ,non projectile ,non blood tinged with food particles as contents
C/o constipation and decreased appetite since 10 days
C/o pain in the back while coughing 
No H/O Burning micturition,loose stools,pain abdomen
No h/o pedal edema,chest pain, facial puffiness,decreased urine output,SOB, palpitations 

PAST HISTORY:
No similar complaints in the past
N/K/C/O - DM,HTN,TB, Asthma, Epilepsy, CVA, CAD, Thyroid disorders.
H/o NSAID abuse present 

PERSONAL HISTORY:
Diet- Mixed
Appetite- Decreased since 10 days
Bowel & Bladder Movements- normal
H/O Constipation since 10 days
Sleep - Adequate
Addictions - None
Family history- Not Significant

GENERAL EXAMINATION-
Patient is Conscious, Coherent and Co operative .
Pallor present
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal oedema
Vitals:
TEMP: 100.6F
BP: 100/70mmHg
PR: 112 bpm
RR- 16cpm
Spo2- 98% 


SYSTEMIC EXAMINATION:
CVS: 
Inspection-
Chest wall is bilaterally symmetrical.
No precordial bulge is seen 

Palpation-
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 
Auscaltation-
S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM:
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds

CNS:
Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact



PER ABDOMEN:
On inspection:
All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars, engorged veins ,sinuses.

On palpation:
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity

On percussion:
Tympanic note - heard 

On auscaltation:
Bowel sounds heard 


PROVISIONAL DIAGNOSIS:
PYREXIA UNDER EVALUATION

INVESTIGATIONS:


Serum creatinine



CHEST X ray

TREATMENT:
1.Inj- NEOMOL 1gm SOS
2.Inj.OPTINEURON 1AMP IN 100 ML NS IV/OD
3.Inj.Zofer 4mg IV/BD
4.Tab.PCM 650mg PO/BD
5. Tab.levocetrizine PO/BD
6.IV FLUIDS NS,RL @75ml/hr
7. SYP.ASCORYL -LS 5ML PO/TID
8.SYP.CREMAFFIN PLUS 15ML PO

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