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60F Fever with productive cough


THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Complaints-
A 60yr old female came with complaints of    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-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 signs of  ,Icterus Clubbing, Cyanosis, Lymphadenopathy




Vitals-
TEMP: 100.6F
BP: 100/70mmHg
PR: 112 bpm
RR- 16cpm
Spo2- 98% @RA

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
RBS -

LFT




Hemogram


Serology


RFT


Serum Electrolytes -
UKB

CUE

ECG

2DEcho - 

Chest Xray - PA view
USG Abdomen




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/BD










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