60/F WITH FEVER ,COUGH,DIFFICULTY AND PAIN DURING SWALLOWING

A 60 year old female came to GM OPD with Chief Complaints of fever since 3 days and cough associated with sputum since 3 days.Difficulty in swallowing and pain during swallowing since 3 days, hoarseness of voice since 3 days shortness of breath since 3 days


HOPI:

The patient was apparently asymptomatic 3 days back then she developed high grade fever, cough with sputum which is whitish in coour non foul smelling and  non blood stained. There was a history of difificult in swallowing & pain  during swallowing there  h/o shortness  of breath 3 days back grade -II. decreased appetite since 5-6 mon ths, loss of weight since 1 year.( 20kg wt loss)


PAST HISTORY:


History of giddiness and fall ,followed by unconsciousness.

Known case of hypertension since 1 year but since 5-6 months not on regular medication . Known case of thyroid disorder since 1 year on medication. known case of DM || since ⑨ years and medication since then, tab- glibeclamide in morning, citagliptin and metformin afternoon, not a known case of epilepsy, Tb ,asthma.

No surgical history

PERSONAL HISTORY:

Diet - mixed 4 times meals per day

Appetite - decreased

Bowel and bladder - frequent micturation

Sleep - adequate,

No addictions

GENERAL EXAMINATION:

  pt is ccc moderately built and moderately nourished, well oriented with place and time,

No pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy.

Vitals:

Pulse rate- 123

Bp - 110/80

Rr- 22

Temp- 99 F

Oxygen saturation 96%


Systemic examination:

CVS: no thrills ,cardiac sounds S1& S2 heard. no cardiac murmers.

Respiratory: dyspnea and wheeze present. normal vesicle breath sounds and position of the trachea central .

Abdominal examination: no soft organomegaly

CNS: NFND







Investigations::                                                                




























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