PREFINAL EXAMINATION ( A 45 yr old female with fever and sob)

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 patient's 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 the comment box.
CHEIF COMPLAINT:
A 45 yr old female  patient  came to the causality with a complaint of  
Fever with chills since 10days 
Shortness of breath( grade 3)chest pain  since 3 days 
Loose  stools and vomiting  since  a day
Date of admission  7/12/22
HISTORY OF PRESENT ILLNESS  :
Female patient who is homemaker was apparently asymptomatic 10 days back then she noticed  fever with chills aggravated at night and subsided by mrng since10 days Shortness of breath( grade 3) and chest pain since 3 days and went to local doctor he gave ORS then she had vomiting( food particles) 1 episode,nausea , loose stools 3 to 4 episodes
Cough (dry) present  since 3days
No h/o hematuria,rash,burning micturation 
PAST ILLNESS  :
no h/o hypertension,diabetes ,epilepsy asthma, thyroid , tb
no h/o any surgeries 
PERSONAL HISTORY  :
Married
Diet : mixed 
Appetite  : decreased 
Sleep : adequate 
Bowel and bladder movements  : regular 
Menstrual history :  menarche  13yrs menopause 3months back 
Addiction : Toddy   ccasionally  stopped 1yr 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 history  : no h/o allergy to known  drugs 
FAMILY HISTORY  : 
No relevant family history 
GENERAL EXAMINATION  :
patient is conscious coherent cooperative well oriented to time place and person 
Pallor present 
No cyanosis clubbing edema icterus 
Vitals 
Temperature  : 98.6f
BP: 60/40 mmhgon7/12/22
90/60mmhg on 8/12/22
110/80mmhg on 9/12/22
RR :  22cpm
PR: 88bpm
SYSTEMIC EXAMINATION  :
CVS : no cardiac murmurs , s1s2 heart sounds heard 
Respiratory system : upper  respiratory tract
No abnormalities  detected 
Lower respiratory tract  :
On inspection  :
Chest : symmetrical 
Trachea : central
No crowding of ribs
Respiratory movements : symmetrical movements 
No dilated veins scars sinuses
No supra or infra clavicular hallowing
Palpation :
Chest movements :symterical movements 
Measurements of chest expansion : 
Complete : 35.5cm on inspiration 
35 on expiration 
Hemithorax  :16cm 
Anteroposterior  : 10cm
Axial diameter  : 13cm
Ap/ Axial diameter: 10/13
Vocal fremitus : increased 
 percussion : 
Right side : supramammary and ,inframammary  : dull note
Left side : supramamary  and 
inframammary  : dull note
On auscultation  :
Breath sounds :fine crept sound heard, wheeze 
Abdomen  : 
Shape : scaphoid
Not palpable liver and spleen
Upper abdominal  tenderness 
CNS : conscious,  speech : normal
No neck stiffness 
PROVISIONAL DIAGNOSIS:  pneumonia secondary to viral pyrexia 
INVESTIGATIONS :
Chest  x ray



Ultrasound 
ECG
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

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