General medicine case_3

     This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed crinformed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

AMC BED2

45 year oldfemale Patient came to the causality 

with the cheif complaints of
SHORTNESS OF BREATH (GRADE 2- GRADE 3), according to NYHA CLASSIFICATION.
ASSOCIATED WITH ORTHOPNEA /PND SINCE 15DAYS.


History of present illness

C/O FEVER WITH CHILLS AND RIGORS SINCE 15DAYS.
No diurnal variation.
Subsided on taking medication.

Past history
Not a k/c/o HTN, DM, ASTHMA, TB, EPILEPSY, THYROID.

No similar complaints in the past.
No significant family history.

Personal history:
Takes mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements.
No known allergies.
Not an alcoholic.
not a smoker.

General examination

Pt is concious, conherence,cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temp:103°f
Bp: 100/80mmhg
Pr:144bpm
RR: 28cpm
SPO2: 97% RA
GRBS: 285mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: DYSPNEA GRADE 4-GRADE 3. No wheeze.
  Trachea position-central.
  Vesicular breath sounds heard
Per abdomen:
Shape: scaphoid.
Bowel sounds heard .
CNS: NAD 

INVESTIGATIONS:












Blood and urine cultures sent.

30/11/21

PROVISIONAL DIAGNOSIS:
COMMUNITY ACQIRED PNEUMONIA.
With fever
?ATYPICAL PUEMONIA
?DENOVO DIABETES MELLITUS TYPE 2

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