PRE-FINAL BLOG(GENERAL MEDICINE BLOG-12) 45 YEAR OLD WITH FEVER AND SHORTNESS OF BREATH
10th December, 2022.
A 45 year old female patient, home maker, resident of Devarakonda came to our hospital with cheif complaints of chest pain, fever, shortness of breath.
Date of admission:-07/12/2022
History of present illness:-
Patient was apparently asymptomatic 10 days back and then, she noticed fever which is associated with chills and rigors with diurnal variation increased during night and subsided by early morning for 3 days, chest pain since 3 days, giddiness and shortness of breath(Grade 3) while walking since 3 days after that, she went to near by RMP, he gave ORS from then she had 1 episode of vomiting(content-food particles) loose in consistency and 4 episodes of loose stools and dry cough since 3 days.
No history of hematuria
No history of rash
No history of burning micturition
History of past illness:-
No relevant past history
Personal history:-
Patient has normal eating habit with mixed diet.
Appetite:-Decreased
Sleep:-Adequate
Bladder and bowel movements:-Regular
Menstrual history:-
Menarche-13 yrs
Menopause- 3 months back
Consumed Toddy occasionally and stopped 1 year back
Daily routine:-
Patient used to wake up at 6.00AM , does homely work, takes breakfast at 9.00AM, takes rice in between 1.00PM-2.00PM, dinner at 9.00PM and goes to bed by 11.00PM.
Drug and allergic history:-
No history of drug and allergic history
Family history:-
No significant family history.
General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Pallor present
No Icterus
No Clubbing
No Lymphadenopathy
No Edema of feet
No Malnutrition
Systemic examination:-
Respiratory system-
Inspection
Chest-Symmetrical
Trachea-Midline
No crowding of ribs
No scars
No sinuses
No dilated veins
Respiratory movements-Symmetrical
No supra or infra clavicular hallowing
Palpation
Trachea-Midline
No crowding of ribs
Chest movement-Symmetrical
Measurement of chest expansion-
On inspiration-35.5cms
On expiration-35.0cms
Hemithorax-16cms
Anteroposterior diameter-10cms
Axial diameter-13cms
AP diameter/Axial diameter=10/13
Vocal fremitus-Increased
Percussion-
Clavicles-Normal
Right side-Resonance at supramammary level
Dullness started at supramammary level
Left side-Resonance at supramammary level
Dullness started at supramammary level
Bronchial Artery Embolism
Wheeze
Cardiovascular system-
No cardiac murmurs
S1S2 heart sounds heard
Abdomen-
Soft
Tenderness at upper abdomen
Central Nervous System-
No abnormality detected
Vitals:-
Temperature-98.6 F
Pulse rate-88 bpm
RR-22 cpm
BP-60/40 mmhg on 07/12/2022
90/60 mmhg on 08/12/2022
110/80 mmhg on 09/12/2022
SPO2-97% at room temperature
Provisional diagnosis:-
Pneumonia secondary to Viral pyrexia
Investigations:-
Chest X-ray
Colour doppler-2D Echo
ECG
Ultrasound abdomen
Chest X-rays
Colour doppler 2D echo
ECG
Ultrasound abdomen
Final diagnosis:-
Pneumonia secondary to Viral pyrexia
Treatment:-
1. Inj. Norad 2amp in 46ml × NS infusion increase or decrease according to Mean Arterial Pressure
2. Pan 40mg × IV × OD
3. Inj. Zofer 4mg × IV × SOS
4. Tab. Dolo 650mg × PO × SOS
5. Plenty of oral fluids with ORS sachets
ORS 4 sachets in 1L of water
6. Tab. Ecosprin 75mg × PO × HS
