62 yr old female with headache,fever and productive cough
12 sep 2023
Hi, I am P.Durga Bhavani 5th Sem Medical Student.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.
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Chief complaints
62 year old female,resident of suryapet,daily wage labour by occupation came to OPD with chief complaints of
- headache since 1 month
- fever since 10 days
- cough since 10 days
History of presenting illness
Patient was apparently asymptomatic 1 month ago then she had headache localised at parietal region which radiates to neck and spine accompanied with fever,cold,cough
Pt c/o fever- high grade,associated with chills and rigor , intermittent no diurnal variations
Pt c/o cough-It was associated with productive cough since 10 days, aggravated by exposure to cold weather, not relieved by medication and the sputum is white in colour and mucoid in nature.
No h/o chest pain,SOB,orthopnea
No h/o sweating, palpitations
No h/o loose stools,nausea,vomiting
No h/o burning micturation,decreased urine output
No h/o weight loss
Daily routine
Before she was sick,she used to wake up at 5am evey morning ,cook for her and her husband,take a bath at 6 am ,wash clothes and dishes by 8.30am ,eat breakfast of rice and vegetables and leave for work by 9 am .She is a daily wage labroer by occupation and used to pack lunch which was same as her breakfast .She used to reach home by
7-8 pm after which she would prepare dinner and sleep by 11pm.
After she got sick,she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past history
Not a k/c/o DM/HTN/CAD/Thyroid/TB
Surgical history -she had hysterectomy 20 yrs ago
Personal history
- married
- decreased appetite
- mixed diet
- regular bowel and bladder movement
- no known allergies
- addictions:toddy drinker but ceased 20 yrs ago
Family history -not significant
General examination
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- pallor present
- no icterus
- no cyanosis
- clubbing of fingers present
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals
- Temperature: 95°F
- Pulse: 88/min
- RR: 20 cycles/min
- BP: 130/70 mm Hg
Fever chart
Systemic Examination
Cardiovascular System
Inspection
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation
- S1,S2 are heard
- no murmurs
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- wheeze present in bilateral suprascapular, infrascapular and mammary areas
Abdomen
- shape: obese
- no tenderness
- no palpable mass
- no bruits
- no free fluids
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination :normal
- P/R examination:normal
Central nervous system
-levels of consciousness: conscious
-speech:normal
-signs of meningial irritation :
no neck stiffness
no kernings sign
-cranial nerves: normal
-motor system:normal
-sensory system:normal
-Glasgow scales:15/15
-reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations
X Ray
ECG
Hemogram on 11/09/23
Hemogram on 12/09/23
Malaria Parasite testing (negative)
Provisional diagnosis
Pyrexia secondary to lower respiratory tract infection with h/o bronchial asthma (exacerbation)
Treatment
INJ. Neomal 1gm iv
TAB. Paracetamol 650mg
TAB. Levocetrizine
SYRUP. Ascoril- LS
TAB. Azithromycin
TAB. Amoxicillin
