A 70 yr old women with sob and fever
September 10th,2022
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Chief complaints:
Shortness of breath grade 4, from 10 days ,fever from 10 days,loss of appetite from 6 days ,burning micturition from 4 days,decrease urine output s from 4 days.
History of presenting illness:
Patient was apperantly asymptomatic 10 days back then she had SOB grade 4 and fever which is intermittent associated with rigors and chills and relieved on medication.
Patient was taken to hospital 8 days back and diagnosed as typhioid and was treated for the same.
Patient c/o of burning micturition and decreased urine output 4 days back.
History of past illness:
K/c/o dm from 15 years (treatment with metformin 500mg)
K/c/o HTN from 10 years (treatment with telmisartan 40/12.5mg)
N/k/c/o of TB,cad, epilepsy,asthma.
Daily routine:
She wakes up at 5 am
She does her breakfast at 8 to9 am.daily roti.
She does her household work .
She has lunch at 1.30 pm roti or rice .
She takes rest ,
She takes her dinner around 8 pm .
She sleeps daily at 9 pm.
Family history:
No significant family history.
Personal history:
Appetite normal.
Mixed diet.
Regular bladder and bowel movements.
No allergies .
Addictions:
Alcohol taken occasionally
Tobacco smoking daily 3 times since childhood.
General examination:
Patient is c/c/c well oriented to time and place .
BP:110/80mm hg.
PR:98bpm
RR:16cpm
No pallor/icterus /cyanosis/clubbing/lymphadenopathy/
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