60 yr old female with viral pyrexia,? COPD

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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.

Unit 6 admission

AMC bed 2

60yr/F

A 60 yr old female came to the casualty with chief complaints of fever since 3 days 

c/o dry cough since 3 days 

c/o SOB since 1 day

patient was apparently alright 3 days ago and then developed fever which was intermittent ,not associated with chills and rigors

c/o dry cough not associated with sputum since2 days

SOB since morning

c/o constipation since 4 days,and generalised body aches,

no c/o of vomitings, loose stools and burning micturition

no c/o malena,hematemesis, bleeding gums,rashes

no c/o pedal edema ,facial puffiness,and decreased urine output

past history 

not a known case oc HTN,DM,CAD ,CVA

appetite- normal

bowel movements- regular

micturition- normal

no addictions

no significant family history

general examination

no pallor,icterus, cyanosis, lymphadenopathy and edema

pulse rate: 113bpm

BP: 110/60 mmHg

respiration: 24/min

spo2 : 95%at RA

GRBS: 149mg/dl

CVS

s1,s2 heard

RS :

BAE + ,NVBS

Abdomen:

soft,non tender

CNS: 

NAD

provisional diagnosis

viral pyrexia , ? COPD

Treatment

1) IVF 

  2 pint NS 

  2 pint RL

  1 pint DNS @100 mp/hr

2) Tab.Dolo 650 mg po/Qid

3)Neb.Duolin 8th hrly

             Budecort 8 th hrly

4)inj.neomol 1 gm IV /sos ( if temp > 101F)

5)GRBS 12 th hrly

6)inj.pantop 40 mg IV/OD

7) vitals monitoring 4th hrly

8) plenty of fluids (4 lit /day)

Soap notes Day 2

 Ward case 60 yr old female

S :

No fever spike

No complaints

O :

O/E , pt is C/C/C

Temp - 98.6F

BP- 90/60 mmhg

PR - 102 BPM

CVS - S1S2 +

RS - BAE + , NVBS

CNS - no focal deficits

P/A: soft non tender , BS +

A : viral pyrexia

        ? COPD

P :

1) IVF :2 NS,1RL @ 100 mL / HR

2) TAB : Dolo 650 mg Po TID

3) Neb Budicort 8 th hrly

      Duolin 8 th hrly

4) inj neomol 1gm IV SOS

5) Tab . Pan 40 mg Po OD

6) plenty of oral fluids

7) syp . Gryllinctus 10 ml po od