A 50 year old female with fever and cough

MEDICINE CASE 

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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.