A 50 year old female with fever and cough

MEDICINE CASE 
This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A 50 YEAR OLD FEMALE WITH FEVER AND COUGH.

A 50 year old female came to the casuality with chief complaints of fever and cough since 5 days.
History of present illness-
Patient was apparently asymptomatic 5 days back,then she developed fever which is of high grade,associated with chills and decreased on taking medication.She has cough since 5 days,which is non productive associated with sob grade 3-4 at rest.No history of cold,pedal oedema,decreased urine output,abdominal distension.
Past history-Not a k/c/o diabetes, hypertension,asthma, tuberculosis, epilepsy,cva,cad.
Treatment history-Not significant
Personal history- Not significant
Family history- Not significant.
On examination-
Bp-120/90
Pr-74
Rr-17
Temp-99 °F
Cvs-s1,s2 heard,no added sounds,no murmurs.
Resp-BAE +, NVBS heard
Per abdomen- NAD
CNS-NAD
Investigations-
17/9/21-

Haemogram-
Cue- 
Abg-
Urinary electrolytes-
Sodium-309,Potassium-39.0,chloride-373.
Blood urea-64
Serum electrolytes-
Sodium-139,potassium-6.0,chloride-99
Serum creatinine-2.3
ECG-
Chest x ray pa view


Provisional diagnosis- Pneumonia secondary to community acquired?,viral?,left greater than right ,With denovo detected diabetes mellitus?,with?  CKD.
Treatment given-
Inj .piptaz 4.5 gm IV stat followed by inj.piptaz 2.25 gm/IV/tid.
Inj.pan 40mg/IV/od
Inj.optineuron 1 amp/IV/od
Inj.neomol 1 gm/IV/sos only if temperature greater than 102°F.
Tab.650 mg/po/sos
Nebulization with duolin 4 repsules stat.

Yesterday as she tested positive for covid-19,we referred her to a covid-19 centre.

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