A 40 year old female with community acquired pneumonia

March 08, 2021

DR.CHETANA (INTERN)

DR.NAVYA (INTERN)

DR.ABDUL RAHEEM (INTERN)

DR.ASHFAQ(INTERN)

DR.SRAVYA(INTERN)

DR.GNANADA(INTERN)

DR.CHARAN(PG1)

DR.CHANDANA (PG 1)

DR.SUSMITHA(PG2)

DR.ADITHYA (PG3)

DR.PRANEETH(PG3)

DR.PRAVEEN NAIK (ASS.PROF)

DR.RAKESH BISWAS(HOD)

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Here is a case I have seen -

Unit 1 admission on 8/3/21

A 40 year old female came with c/o fever since 4 days and SOB since 1 days
HOPI-
Pt is k/c/o polio since age of 8 months with deformed lower limbs and spine since childhood. Inspite of her deformities ...she used to do all her chores by herself like cooking , washing, cleaning and completed her 10 th class
She was alright till 6 years back .
6 years ago she had history of fever and cough during which she was diagnosed with pneumonia and took some injections near the local RMP ? Antibiotics .
Since 10 months, she reports decreased appetite , indigestion and on and off chest pain after eating meals.
History of weight loss of 5 kgs since last 10 months.
Since 4 days, she complains of high grade fever, intermittent type , not a/w chills and rigors, relieved on medication, no diurnal variation.
C/o dry cough since 3 days.
H/o vomitings 2 days back, 3 episodes with food as content.
H/o of loose stools 2 days back, 3 episodes, watery in consistency, in small volumes.
Vomitings and loose stools subsided now.
Since yesterday evening, she developed SOB which progressed from Grade 1 to Grade 4.
She presented to casualty with GRADE 4 SOB.
No h/o burning micturition, chest pain , cold.
Not a K/C/O DM HTN TB Epilepsy CAD
Decreased appetite
Regular B&B movements
Menstruated history -
AOM 12 yrs
Cycle - 4/30
Regular
No clots, no dysmenorrhea
General examination-
Wt -

Pallor-present
No signs of icterus , cyanosis , clubbing,
No generalised lymphadenopathy, generalised edema
Vitals -
Temp-102F
Bp-140/90mmhg
PR-135 bpm
RR-34cpm
SPO2- 90 @ 4 lit O2
GRBS-137mg/dl
Calluses present over fingers and plantar aspect of foot
Flexion deformities of both lower limbs
Flat nails
Kyphoscoliosis is present
On examination-
RS-
Dyspnea-present
Wheeze -present
B/L Parasternal bony prominences + (clavicle)
B/L coarse crepts + , not subsiding with cough in Rt ICA, IMA, IAA and Lt IAA
P/A-
Shape of abdomen- normal
Non tender
No palpable mass
Hepatomegaly is present
CVS-
S1,S2 +,
Tachycardia Is present
No cardiac murmurs
CNS- NAD
Provisional diagnosis-
Community acquired pneumonia