A 70 year old female with shortness of breath

- September 11, 2022

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A 70 year old female came to opd with the chief complaints of shortness of breath since 10 days,fever since 10 days ,burning micturition and decreased urine output since 4 days , loss of appetite since 6 days,

HOPI : patient was alright 11 days back then she developed fever which is insidious in onset ,high grade,intermittent in nature associated with chills and rigor and it releived on taking medication .she is having shortness of breath grade 4 since 10 days,it aggravated 3 days back ,patient also complains of burning micturition and decreased urine output since 5 days

patient gives a history of diabetes mellitus from the past 15 years ,hypertension from 10 years ,she is taking medications tab metformin 500 mg po/od,tab telma 40 12.5 mg po/od, patient was taken to hospital 9 days back,and there diagnosis of typhoid was made and treatment was given

past history: K/C/O DM from 15 years

HTN Since 10 years

patient is not a k/c/o TB ,ASTHMA,CAD,EPILEPSY.

personal History:

She consumes mixed diet

Appetite is decreased in the past 6 days

Sleep is adequate

Bowel regular and decrease in urine output.

No addictions.

Family history: no significant family history

GENERAL PHYSICAL EXAMINATION: patient is conscious, coherent,cooperative well oriented to time ,place and person .she is obese and moderately nourished.

pallor present

icterus absent

clubbing absent

cyanosis absent

lympadenopathy absent

edema present

VITALS at time of admission

Bp: 130/90 mm Hg

pulse rate: 90 bpm

respiratory rate: 20 cpm

temperature: 98.9°F

spo2: 98

GRBS: 230 mg/ dl

systemic examination

CVS:

precordial bulge is not seen

apex beat is present at 5 th ICS

S1 and S2 heart sounds heard

RS:Bilateral air entry present, shape of chest is normal,patient is having severe dyspnea ,trachea appears to be normal in central position,spine appear to be central,no visible scars ,sinuses,dilated veins,movements of all areas appear to be equal

vocal fremitus is felt equal on both sides,normal vesicular breath sounds

Per abdomen:

shape of abdomen distended

flanks are full

all quadrants move equally with respiration

umblicus central and inverted

skin is normal

no visible masses ,dilated veins,no scars or pigmentation,no hernial orifices,no local rise of temperature,no guarding rigidity,no palpable organomegaly,abdomen is soft ,non tender,no shifting dullness and fluid thrills,bowel sounds heard

CNS: No focal neurological deficits