60yrs /F with Pain in chest , breathlessness,and fever

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
25/11/22

CHEIF COMPLAINT
60yrs /F  farmer by occupation came to OPD with c/o Pain in chest , breathlessness,and fever on 26/11/22

HOPI(History of present illness):

Patient was apparently asymptomatic 4 days back
Then  day she developed breathlessness gradually progreessed from mMRC grade 2-3
History of fever 2days 
And there is  history of Vomitings and nausea ,fever,
history of chest pain 2 days dragging pain


PAST HISTORY:
a K/c/o HTN for 1 yrr on treatment medication T.Aten 50 mg OD
                     T.Amlodepine 5 mg OD

Not a K/c/o DM, BA , Thyroid disorder and Epilepsy.
Hysterectomy -18 yrs back

PERSONAL HISTORY:
Married
Occupation -Farmer
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
She have habit of drinking toddy and stoped before 1 year
No habit of betel nut, beatel leaf 

FAMILY HISTORY:
No similar history in the family
Obse

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-No dehydration 

 ▪️VITALS:
Temperature - 99F
Pulse rate - 98 bpm
Respiration rate - 32cpm
BP - 140/70 mmhg
SpO2 - 84% @ RA at 95% 6lit of O2
GRBS-236mg %

SYSTEMIC EXAMINATION:

▪️CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

▪️RESPIRATORY SYSTEM 
Upper respiratory tract
Nose no DNS polyps  tuburinate  hypertropy
Oral cavity poor oral hygiene
Posterior Pharyngeal wall

Lower respiratory tract
Shape of the chest bilaterally symmetrical                                    elliptical
Trachea appear to be central
Supra clavicular and infra clavicular Hollowness
Crowding of ribs and dropping of shoulder absent
Muscles wasting- absent
Apical impulse -not seen
Kyphoscoliosis- absent
Scars and pigmentation -absent

Palpation
All inspestory findings are confirmed
No local rise in temperature
Trachea central
Apex beat.  5th intercoastal space along the mid clavicular line

Percussion

Direct -resonant 
Indirect - dull. In left infra axillary area
                          Interscapular area and                                     interscapular area

                              Right.     Left
 Supra clavicular.  R.            R
 Infra clavicular     R.            R
Infra axillary.          R.           Dull
Suprascapular .    R.              R.   
Interscapular.       R.             Dull         
Infrascapullar.       R.              Dull

Ascultation
Crepts are heard
Vesicular beath sounds


▪️CNS
 No nerological defect

Provisional diagnosis
Bilateral lung consolidation secondary to 

Investigation
ECG
2D echo
Blood count 
Rft and Lft

Treatment 
O2 inhaltion through face mask
 Inj. Agumentin 1.2gm/i.v/TID

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