60 yr old female with fever, difficulty in swallowing,hoarseness in voice



GM Blog: 60 year old female patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 31-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of fever since 3 days and c/o cough associated with sputum  since 3 days 
C/o hoarseness of voice and throat pain since 3 days 
C/o decreased appetite since 5-6 months 
C/o weight loss approximately 20kg over the last 1 year.


HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 3 days back then she got fever and cough associated with sputum. She also had hoarseness of voice since 3 days.
She had loss weight of 20 kg over 1 year.

PAST HISTORY:

Hypertension since 6 months not on regular medication 
Hypothyroidism since 1 year on regular medication
Diabetes mellitus since 6 years on regular glimiperide 1mg , metformin 500mg and saxagliptin 50mg


PERSONAL HISTORY:
Married 
Moderately built and nourishment.
Diet: mixed. ( Non vegetarian)
Sleep- normal
Appetite - reduced 
Bladder movement- normal
Bowel movements- normal
Allergy-no 
Addiction- no


FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
She is well oriented to time, place and person. 
She is moderately built and nourished  
Pallor - absent 
icterus absent
No cyanosis
No clubbing
No edema 
No Lymphadenopathy 


Vitals
Temperature: 98.1 F 
Heart rate : 123 beats /min
Respiratory rate: 22/ min
Blood pressure: 110/ 80 mmHg 
Spo2-94 %
Random blood sugar: 155 mg /dl
Systemic examination

Cardiovascular system:
S1, S2 heard
No murmurs 

Respiratory system:
Creeps Heard at infrascapular and axillary region 
Wheeze and dyspnea present
Position of trachea: central
Breath sounds: Vesicular
Adventitious sound: bilateral ronchi present 

Abdomen:
Shape of abdomen: scaphoid
Non tender
No palpable mass
No free fluids
Spleen and liver not palpable

Central nervous system:
Conscious
Speech: normal
Neck stiffness - no

ENT examination
Arytenoids: minimal edema
Lingual tonsil hypertrophy
Laryngeal crepitus decreased on left side 
DIAGNOSIS 
LRTI WITH COMMUNITY ACQUIRED PNEUMONIA
(RIGHT LOWER LOBE CONSOLIDATION)
K/C/O HTN,DM,HYPOTHYROIDISM
BRONCHECTASIS WITH DIABETIC NEUROPATHY
FACTITIOUS DISORDER(RESOLVING)
TREATMENT:
.IVF NS@75ML/HR
. NEBULIZER WITH DUOLIN-TID
.BUDECORT-BD
.INJ.AUGUMENTIN 1.2 g IV BD
.TAB AZITHROMYCIN 500 MG PO OD 
.TAB THYRONORM 50 MCG PO OD
.TAB PREGABALIN 75 MG PO HS
.TAB B COMPLEX PO OD
.INJ PAN 40 MG IV OD
.TAB PCM 650MG PO SOS 
.TEMP AND BP MONITORING 6 TH HOURLY
.STRICT I/O CHARTING



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