A 60 yr old female with cold and cough since 10 days, fever since 8 days

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I have 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 diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER

Chief complaints:

A 60 yr old female,homemaker who is a resident of Nalgonda came with chief complaints of cold and cough since 10 days, fever since 10 days .

HOPI:

Patient was apparently asymptomatic 10 days ago then she had cough and cold, aggravated with cold climate and relieved with medication. Cough is productive,whitish, non foul smelling and persistent.

H/o watery nasal discharge, on and off, aggravated with cold climate and relieved with medication.

Fever is of low grade, intermittent, not associated with chills and rigors.

Past history:

K/c/o HTN since 20 yrs and is on medication ( Aten 25)

N/k/c/o DM,TB,Asthma,CVA,CAD,Epilepsy 

Daily routine:

She wakes up at 5 am and does her chores like cleaning and mopping the house and by 8 am ,she freshens up and has breakfast and then washes clothes. After that she cooks food have lunch by 12 pm. After that she takes nap and does other activities like gardening, going to market etc and by 7 pm she takes dinner . She then sleeps by 9 pm.

On examination:

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

No pallor,icterus,cyanosis, clubbing,lymphadenopathy or edema

Vitals:

Afebrile

BP: 120/80 mm Hg

PR: 64 bpm

CVS: S1,S2+, no murmurs

RS: BLAE+, No added sounds

CNS: NFND

PA :Soft and non tender