A 60 year old female resident of thakkellapally who is a housewife came with the complaints of fever since 10 days nausea and vomiting since 10 days and productive cough since 10 days 

History of present illness 

Patient was apparently asymptomatic 10 days back then she developed fever which is insidious in onset ,continuous with no diurnal variations and not associated with chills and rigors ,relived on medication ,no history of headache

history of vomiting and nausea since 10 days almost 2 times a day which is non projectile, non bilious with loss of appetite 

Complains of Bilateral knee pain for which she is taking NSAIDS since 5 years,no history of other body pains

Cough with expectoration with mucoid sputum and associated with pain in back while coughingk

No History of burning micturition ,loose stools, pain abdomen ,pedal edema,chest pain, Shortness of breath, palpitations 

Past history

Not a known case of diabetes ,hypertension ,asthma ,epilepsy,coronary artery disease

History of NSAID abuse

Personal history 

Diet - mixed 

Appetite- decreased since onset of fever

Sleep - adequate 

Bowel and bladder movements - normal

No addictions

No food allergies or drug allergies 

Family history

No significant findings

On physical examination 

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

Pallor-present

No icterus ,cyanosis,clubbing,lymphadenopathy, edema 

Temperature-98.9 

Pulse rate - 112 

Respiratory rate- 16

Blood pressure-100/70

Systemic examination 

CVS:
Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen 
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 
Auscaltation-
S1&S2 are heard,no murmur found

RESPIRATORY SYSTEM

Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact







Provisional diagnosis 
   Pneumonia 

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