70 year old female with fever and SOB

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I’ve been given this case to solve in an attempt to understand the topic of “patient 

clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Following is the view of my case :

Date of admission : 30/10/2022

Chief complaints :fever since 20 days

Shortness of breath since 1day

History of presenting illness:

Patient was apparently asymptomatic 20 days back then she developed fever which was high grade and intermittent type,associated with generalized body weakness,chills, she went to a rmp near by and took some medication which relieved the fever for 2 days and again fever get started she went to another hospital in miryalaguda where she was diagnosed with Dengue and treated but she developed pain abdomen from 3 days and SOB since 1day for which she underwent an USG and diagnosed as ascites and was referred to our hospital She was complaining about difficulty in swallowing since 3 days

Past history:

Not a known case of DM,HTN,TB,CAD AND CVA,ASTHMA , EPILEPSY

FAMILY HISTORY:

NOT significant

Personal History:

Diet-mixed

Appetite-reduced

Bowel and Bladder movements- bowels movements reduced

Addictions:no

Allergies:no

Drug history:not significant

General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

at the time of examination

She is examined in a well lit room, with consent taken.

SHe is moderately built and moderatly nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission :30/10/2022

Temperature - afebrile

Pulse rate - 82 bpm

Respiratory rate - 24 cpm

Blood pressure - 110/90 mmHg

SpO2 - 94% on Room air

GRBS -  92mg/dl

Systemic examination:

CVS:S1,S2 heard

RS:BAE present,NVBS heard

CNS:intact

Per abdomen: soft ,tender,no organomegaly detected

Investigations:

Diagnosis:

Pyrexia under evaluation

Treatment:

1)IV FLUIDS 2*NS,1*RL@100ml/hr

2)Tab PCM 650 mg PO TID

3)Tab Pan 40 mg PO OD

4) Temperature monitoring 4th hourly

5) Vitals monitoring 4 th hourly

6)Chlorexidine gargles in water 4times/day