Friday, December 3, 2021

70 year old female patient

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Unit 5 admission 

A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +

Dry cough since 1 year 

H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided

C/o burning micturition since 2 days 

C/o polyuria since 2 days

C/o biomass exposure since child hood daily

H/o on and off SoB since 10 to 15 years,using RMP medication 


HISTORY OF PAST ILLNESS:

No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures 

Not a k/c/oDM,HTN,CAD,CVA,TB


PERSONAL HISTORY:

Occupation:  house wife

Appetite: lost

Diet: Mixed 

Bowel and bladder movements:  Regular

Allergies: None

Habits: None 

FAMILY HISTORY: 

Not significant.



GENERAL EXAMINATION:

Patient is consious, coherent, cooperative 

Vitals:

Temperature : afebrile

RR: 14 cpm 

Bp:  120/80

HR: 105 bpm

Spo2: 100

GRBS: 131 mg%

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.


SYSTEMIC EXAMINATION:

RS: BAE+, Diffuse Wheeze, crepts +

CVS: s1 and s2 heard

P/A: soft, non tender.

CNS: NAD


INVESTIGATIONS:

CBP:

HB:12.3

TLC: 10300

PL: 2.71

CUE:

Albumin and sugars: nil

EC:

PC: 

LFT:

TB: 0.83

DB: 0.20

ALB: 3.8

ALT:  25

ALP: 202

AST: 50

RFT:

UREA: 21

SR. CR: 0.8

UA: 2.0

Na: 141

K: 3.6

Cl: 91

Serology: negative 

ABG:

Ph: 7.443

Pco2: 37.4

Po2: 79.9

So2: 94.5

Hco3(p.st): 25.9

Hco3 pc: 25.2
XRAY:





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