65 years old female with fever since 5 days

A 65 years old female who is a housewife by occupation came to the casuality with the chief complains of -

  1. Fever since 5 days

  2. Dry cough since 5 days

  3. SOB since 2 days

History of present illness: Patient was apparently asymptomatic 5 days ago. Then she developed fever which was- low grade, not associated with chills and rigors.

It was associated with dry cough.

C/O SOB since 2 days (orthopnea present).

C/O chest pain while coughing.

C/O cold since 5 days.

C/O palpitations since 5 days.

C/O giddiness since 1 day.

C/O nausea present.

No h/o vomitings, loose stools.

No h/o decreased urine output.

No h/o burning micturition, pedal Edema.

No h/o rashes.

Past h/o: K/C/O DM and Hypertension.

On Tab. GLIMIPERIDE 2 mg + PIOGLITAZONE 15 mg + METFROMIN 500 mg for DM.

On TAB. TELMA-H (40/12.5) for HTN.

Family history: Not significant 

Personal history: 

        

                 Diet- Mixed

                 Appetite- Normal

                 Sleep- Adequate 

           Bowel and Bladder movements- regular

                  No addictions.

                  No known drug allergies.

General examination:

She is conscious, coherent, cooperative, well oriented to time, place and person. She is moderately built and moderately nourished. 

Pallor- absent 

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Edema- absent

JVP- Normal

Vitals on admission-

Temperature - 98.6 F

PR- 70 bpm

BP- 120/70 mm Hg

RR- 15 cpm

SpO2- 98% on RA

GRBS- 114 mg/dl

Systemic examination:

CVS- S1,S2 sounds heard. No murmurs.

RS- BAE present, Normal Vesicular breath sounds heard.

P/A- Soft, non tender, Bowel sounds heard

CNS- NAD

PROVISIONAL DIAGNOSIS: B/L LOWER LOBE CONSOLIDATION 

? HEART FAILURE

LBBB +

Investigations- 

25/12/21

CXR-

Treatment received:

1. OXYGEN INHALATION 2 litres/SOS

2. INJ. AUGMENTIN 1.2 gm I.V./ BD

3. TAB. AZITHROMYCIN 500 mg PO/OD

4. INJ. LASIX 40 mg I.V./BD

5. SYP. GRILLINCTUS 10 ml PO/BD

6. INJ. HUMAN ACTRAPID INSULIN ACCORDING TO GRBS

7. TAB. MET-XL 25 mg PO/OD

8. TAB. ECOSPIRIN 150 mg PO/OD

9. TAB. ATORVAS 40 mg PO/H/S

10. I/O charting, Tempertaure charting 4th hourly

11. Plenty of oral fluids