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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
PROVISIONAL DIAGNOSIS:
Excarcerbation of COPD
? Viral pneumonia