75 year old female patient presented with fever since 2 days and sob since 4 days

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CHEIF COMPLAINTS.


Patient came with cheif complaints of fever since 2 days , shortness of breath since 4 days ,burning micturation since 4 days 


HOPI


 patient was apparently asymptomatic 4 days  back then she developed Shortness of breath since 4 days which was insidious in onset, gradually progressive( from grade 3 to 4) aggrevated on exposure to cold/early morning and relieved on medications

Patient also complains burning micturation not associated with any urgency, frequency/hesitancy 

Complaints of fever since 2 days, associated with chills and rigors ,insidious in onset ,high grade no aggrevating factors, and relieved on medications 

No c/o chest pain ,orthopnea ,pnd

B/l pitting type of edema.  Extending upto knee


PAST HISTORY 


patient is k/c/o HTN since 12 years and is on medication TAB.MET XL 50 PO/BD

K/C/O  BRONCHIAL ASTHMA since 12 years and is medication


PERSONAL HISTORY 


Appetite: normal 

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient have past habit of taking tobacco snuff


FAMILY HISTORY:


no history of similar complaints within the family


GENERAL EXAMINATION 


Patient is conscious, coherent and cooperative

Well built and we'll nourished

Pallor: absent 

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: present ( B/L pedal edema upto knee region)

 





VITALS:

Temp - 97.5 F

BP 120/80 mmhg

Heart rate 120 bpm

Resp Rate 32/min

Sp02 96%

Grbs 169 mg/ dl


RS 

BAE+ 

NVBS+ ,no crepts

no added sounds


CVS 

S1 S2 heard

 no murmurs


P/A 

soft , tenderness present on suprapubic area,no organomegaly,


CNS 



Higher mental functions intact 

No focal neurological deficit 


PROVISIONAL DIAGNOSIS 

?Acute exacerbation of bronchial asthma, 

?CAP

?Sepsis secondary to UTI( dengue Igm +)

?Pre renal kidney injury on CKD ( STAGE V)


INVESTIGATIONS 













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