54 years female with pneumonia long case

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Daily routine: 

She is a farmer by occupation.

Wakes up at around 7:00 am in the morning. Eats breakfast by 8:00 am. Goes to his farm and monitors work. Then comes back to his house in the afternoon and has lunch by 1:00 pm. Sleeps for a while in the afternoon 

He has a cup of tea in the evening at around 5:00 pm , watches TV for a while and has dinner at around 8:00 pm and goes to bed at around 9:30 pm. 

Chief complaints:

 patient was brought to the casualty  with c/o cough and sputum

HOPI: 

Patient was apparently asymptomatic 1 month ago the she developed  fever which was low grade intermittent and incidious in onset and was gradually progressing and relieved on taking medication 

Fever increasesd gradually from past 4 days which was associated with generalised weakness and body pains 

H/o dysnea which was incidious in onset and gradually progressive  patient  also gives history of pain  in the epigastric region on inspiration

No h/o  chest pain , palpitations , swetting

No h/o nausea, vomiting and loose stools

HISTORY OF PAST ILLNESS:

 Patient was diagnosed with hypertension 6 months ago and he is on medications 

Patient also gives the history of pain in multiple small joints of hand , knee and shoulders since 10 yrs and used aurvedic medicine 

Not a k/c/o  type 2 DM , astham , thyroid disorder 

Personal  history: 

Diet : mixed 

Appetite : decreased

Bowel movement: regular 

Bladder movments : normal

Habits: has a habit of consumption of toddy occasionally

Patient also has  a habit of cheweing betal leaf 

 

FAMILY HISTORY :  

No significant  family history

 Treatment history: 

 Patient is on hypertensive drugs since 6 months 

General examination: 

Patient is conscious, coherent and cooperative 

Patient was examined in well lit room after taking well informed consent.

Patient is moderately built and moderately nourished

No /icterus/cyanosis/clubbing/Generalized lymphadenopathy

Pallor(+)

VITALS ON ADMISSION -

BP :  140/90 mm hg

 PR : 106bpm

temparature: 102.7 f 

RR :30 cpm 

GRBS: 140 mg

SYSTEMIC EXAMINATION:

 

Cvs : S1 s2 heard  no murmurs 

RS : BAE+ 

Vesicular breath sounds , dyspnea (+) 

Wheeze(-)

 

CNS examination: 

Concious

Speech:normal

Gait: normal 

Sensory system :normal

Motor system: normal 

INVESTIGATIONS: 

ECG : 

Chest x ray: 

2D ECO : 

 TREATMENT : 

INJ. LASIX 40mg iv/bd

INJ.NEOMOL 1gm IV/ sos if temp > 101°F

TAB . AZITHROMYCIN 520mg /po/od 

TAB . AGUMENTIN 625 mg /po/od 

Srup . Ascoril 10 ml /po/od 

Provisional diagnosis : 

Pneumonia,  CAD