62 year old female with fever and cough

62 YEAR OLD FEMALE WITH FEVER AND COUGH

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A 62 year old female, labourer ( in farms ) by occupation presented to the OPD with chief complaints of fever and cough since 10 days .

History of presenting illness : The patient was apparently asymptomatic 10 days back , then she developed high grade fever associated with chills and rigors , continuous in nature with no diurnal variation , only relieving with medications . The fever is associated with generalised weakness and body pains .

She also has dry cough that is causing SOB even on sitting or lying down .

She has visited the local doctor for 2 days (was given saline) before coming to our OPD . 

Past history : The patient is not a known case of DM, HTN, asthma, epilepsy, thyroid disorders, CAD, TB .

Personal history : The patient works as a labourer in cotton fields from 8 am to 6 pm 10 days back , but now as she is not well she is not going for work .

Diet - mixed

Appetite - decreased

Sleep - inadequate 

Bowel and bladder movements - regular

Addictions -  consumption of betel leaves 3 times/day since 30 years .

General Examination :  The patient is conscious, coherent and cooperative, well built and nourished .

Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.

VITALS :

Temperature -  99 F

BP - 120/80 mm Hg 

HR - 83 bpm

RR - 16 cpm

Systemic Examination : 

CVS : 

On palpation ‐

• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 

• JVP was normal 

• No precordial bulge 

• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs 

RS :

On inspection ‐

• Chest is bilaterally symmetrical 

• Expansion of chest: Equal on both sides

• Position of trachea: Central

• No visible scars, sinuses, pulsations

On palpation : 

• Expansion of chest was equal on both sides. 

• Position of trachea: Central

• Tactile Vocal Fremitus: resonant note was felt.

On percussion: all lung areas were resonant 

On auscultation : 

• Bilateral air entry was present, normal vesicular breath sounds were heard. 

• Vocal resonance: resonant in all areas

P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.

CNS : The patient is well oriented to time, place, person.

Higher mental functions are intact.

Cranial nerve examination :‐

All cranial nerves are intact and functioning. 

Motor System Examination :‐

• Normal bulk in upper and lower limbs

• Normal tone in upper and lower limbs

• Normal power in upper and lower limbs

• Gait is normal .

. Reflexes are normal .

Sensory System Examination :‐

Normal sensations are felt in all the dermatomes.

No cerebellar signs .

No meningeal signs.

Investigations :

Hemogram

LFT

RFT

ECG

USG of abdomen 

2D echo

Provisional Diagnosis : Pyrexia under evaluation 

Treatment :

1) IV fluids - 50ml/hr

2) Inj. Neomol 1 gm IV SOS if temperature>101F

3) Tab. Amoxicillin - 625 mg PO TID

4) Syrup Ascoryl 10 ml TID

5) Tab. Pantop 40 mg PO OD

6) Tab. Dolo - 650 mg PO TID