72 years old female came with c/o SOB since 3 days , fever and cough since 3 days

Hi, I am Nishanth Reddy Samala, 5th semester medical student. 

This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Chief complaint:

Patient with c/o SOB since 3 days c/o fever and cough since 3 days

History of present illness:

Patient was apparently asymptomatic 3 days ago the she developed SOB which is grade 3, gradually progressive. No c/o orthopnea/PND.

Fever since 3 days low grade ,continous, not associated with chills and rigor.

Cough is productive with white colored  sputum, non blood tinged 

No h/o chest pain,palpitation

No abdominal pain,vomiting, loose stools

Past history:

K/c/o Hypertension, Diabetes mellitus type 2 since 2 years.

N/k/c/o asthma,epilepsy,TB,CAD,CVA.

Treatment history:

Drugs used for Diabetes and Hypertension.

Personal history:

Married

Mixed diet

Normal appetite 

Irregular bladder movements - increased in frequency and burning micturition

Regular bowel movements 

No allergies

No addictions 

Family history:

No significant Family history 

General examination:

Patient is conscious,coherent and coperative.

Well built , moderately nourished and well oriented to time,place and person.

No Pallor

No Icterus

No Cyanosis

No Clubbing of fingers

No Lymadenopathy 

No Pedal edema

Vitals:

Temperature: 101°C

PR: 97 bpm

RR:22 cpm

BP:140/90 mm Hg

SpO2: 83%

GRBS: 174mg%

Systemic examination:

CVS - S1, S2 heard 

CNS - Higher motor functions intact 

PA - Soft and non tender 

RS - BAE+ , NVBS +

Investigations: