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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