Case history-8





A 56 yrs old female ,who works as a farmer presented to opd 4 days back ,with chief complaints of fever ,loss of appetite

History of present illness:

Patient was apparently asymptomatic 1 week back .patient complaints of nocturnal fever (high grade fever  associated with chills ) 

>Along with the fever , she also complains of ear discharge which is mucoid in nature with no blood stained ,with severe pain in ear .she has decreased hearing for soft sounds,non -fluctuant with nasal obstruction.

>She complains of loss of appetite , mild abdominal pain .

>She even suffered with facial puffiness along with cough 

>2 days later she has suffered with grade III shortness of breath 

>she has even pedal edema  which has become normal now .

HISTORY OF PAST HISTORY:

Not a known case of asthma, TB, epilepsy, thyroid disorder

No history of blood transfusion

Patient has hypertension from past 1 week 

Patient has not  undergone any surgery before 


Personal history:

Diet : mixed 

Appetite- loss of appetite 

Sleep- normal 

Bowel and bladder movement- normal 

Addiction - no addiction 

 

Family history: 

No history of DM/ CAD / asthma 

No similar complaints of family history 


Treatment history:

Not significant 


General examination:

Patient is conscious ,coherent, cooperative 

No icterus , no lymphadenopathy, no clubbing, no cyanosis, 

Pallor has been noticed.

No dehydration 

No malnutrition 


Vitals: 

Temp -afebrile

Bp-110/70 mm/hg

Pulse rate-90/min

Respiratory rate-20/min

Spo2-98%


Systemic examination:

1-Cvs-no thrills

        Cardiac sounds- S1,S2

        No cardiac murmur 

2- respiratory system:

        Position of trachea- central 

       Norma bilateral air entry 

       Breath sound is vesicular

      Dyspnea is seen 

3 .abdomen- 

    No tenderness 

    Absence of palpable mass

   Absence of free fluid 

   Liver and spleen-non palpable 

   Bowel sounds are noticed

   

4. CNS:patient is conscious,patient speech is normal with absence of neck stiffness 

Investigation:







◦ 





Provisional diagnosis:

Akc on ckd with secondary viral infections 

Treatment:
1 tab.augmentin - 625 mg
2a tab deoxyckin- 100 g
3.inj lasiz - 20 mg 
4. Ambixol- 10 ml 
Tab . Nadisis



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