60 year old female with fever & cough

A 60 yr old Female with fever & productive cough
July 22, 2023

This is online E log book to discuss out patients de-identified health data shared after taking his/her guardian's 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 patients clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box are welcome.

Chief complaints 
Fever since 10 days
Productive cough since 10 days
Vomitings since 10days

History of Present Illness 
Patient was aparently asymptomatic 10 days back then she developed fever which is of low grade,intermittent,not associated with chills and rigors & relieved on medication
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 are watery,non projectile,non blood tinged with food particles as content
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 history of similar complaints in the past
Not a K/C/O - DM,HTN,TB, Asthma, Epilepsy, CAD, Thyroid disorders.
H/o NSAID abuse present 

Personal History
Diet- Mixed
Appetite- Decreased since 10 days
Normal Bladder Movements
Bowel- Constipation since 10 days
Sleep - Adequate
Addictions - None

Family history
Not Significant

General Examination 
Patient is Conscious,Coherent & Co- operative
Pallor - Present
No signs of icterus, cyanosis, clubbing of fingers, lymphadenopathy, pedal edema
Vitals
Temperature - 100.6F
Blood Pressure -100/70mmHg
Pulse Rate - 112 bpm
Respiratory Rate - 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 murmurs 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 or 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 

Investigations
Random blood sugar
Serum creatinine
Blood urea
Serum electrolytes
Liver function test
ECG
Chest X-Ray



Provisional Diagnosis
Pyrexia under Evaluation
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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