Case history 5
CASE HISTORY 5
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A 45 year old female patient presented to OPD with a chief complaint of :
1. Fever since 5 days .
2. Vomiting and headache since 4 days .
3. Shortness of breath since 2 days .
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 5 days back .
And then developed fever which is sudden in onset and gradually increasing .
Fever is not associated with chills and sweating .
Fever associated is on and off since 1 month .
History of vomiting since 4 days in which food particles are present as content .
History of shortness of breath since 2 days which is more during walking or doing some work .
Bilateral pedal edema is seen which is pitting type .
Loss of appetite is seen .
PAST HISTORY :
there are no similar complaints in the past .
No history of diabetes , epilepsy , asthma ,
PERSONAL HISTORY :
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel and bladder movements are normal
Menopause since 1 year .
FAMILY HISTORY :
There are no similar complaints in the family members .
TREATMENT HISTORY :
patient took medicines for fever and vomiting suggested in the local hospital .
GENERAL EXAMINATION :
Patient consent was taken and she is conscious, coherent and cooperative and examined in well lit room . And well oriented to time and place
Patient is poorly nourished and built
No cyanosis
No clubbing
No icterus
No generalised lymphadenopathy
Pedal edema is seen which is of pitting type and subsided gradually
VITALS :
Temperature: afebrile
Blood pressure: 110 / 90 mmHg
Pulse rate : 84 beats per minute
Respiratory rate : 18 cycles per minute
SPO2 : 98 % in room air
SYSTEMIC EXAMINATION :
RS : BAE is positive
CVS : S1 and S2 are heard
PA : soft and non tender
CNS : NAD
JVP : increased
PROVISIONAL DIAGNOSIS :
Right upper lobe consolidation
Lobar pneumonia
Pre renal AKI
Hypoalbuminemia
Hyperthyroidism
INVESTIGATIONS :
Hemogram :
Pedal edema :
TREATMENT :
1. Oxygen inhalation to maintain SPO2 > 98%
2. NEB - duolin - 8th hourly
Budecort - 12th hourly
3. Inj . Piptaz 2.25 gms /Iv / Tid
4. Inj. Zofer 4 mg / Iv / sos
5. Tab PCM 650 mg/PO/BD
6. Syrup acscoryl 10 ml / po / tid
7. Tab . Lasix 20 mg/PO/BD
8. Inj. Pantop 40mg / Iv / OD
9. Tab . Carbimazole 10mg / Po
10 . Tab .propanolol 20 mg/PO/OD
11. Temperature charting for every 4th hourly
12. Blood pressure , pulse rate , SPO2 charting every 4th hourly .
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