75 yr old with SOB and FEVER.

75 yr old male with SOB and Fever.

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NAME: MEGHANA.M

ROLLNO: 90 

2017 BATCH 

HISTORY: 

Date of admission: 18/10/2021

Patient came with the chief complaints of:

1. SOB since 3 hrs, grade 4

2. Fever since 6 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparantly asymptomatic 1 week back, then he had a fall, no loss of consciousness, and sustained a 2×1cm abrasion on his scalp.

Following this he developed low fever, since 6 days, which is intermittent, not relieved on taking medications, not associated with chills and rigors. 

Shortness of breath since 3 hrs on DOA, grade 4.

PAST HISTORY:

He had a history of repeated falls 1 year back , for which he went to the government hospital.

Initially the patient was told that he had low blood pressure, then after 5 months , he was diagnosed with hypertension and started taking medications.

He had a history of pedal edema and shortness of breath 1 year back for which he came to KIMS . He was diagnosed with Renal Failure and was on conservative treatment for 4 months, then he stopped taking medication and is only on Tab NODOSIS till now.

Patient had the history of fall 1 week back , no history of loss of consciousness, had a small abrasion on the head.

Patient had constipation for 2 days , took DULCOLAX tablets, had loose stools (3 episodes)

The patient is a known case of Hypertension, is on Tab AMLODIPINE 5mg.

PERSONAL HISTORY:

Diet: vegetarian diet since 6 years

Sleep: adequate

Bladder movements: normal

Bowel: Constipation 

Addictions:  He used to smoke 18 beedis/day , smoked for 30 years. After he was diagnosed with Tuberculosis (took treatment for 2 years) , he stopped smoking.

He was an alcoholic , took 90ml/day and stopped 1 year back, now takes occasionally during social gatherings.

Allergies:  No known allergies.

GENERAL EXAMINATION: 

Vitals on admission:

Temperature - 98.4 F

Pulse rate - 92bpm

Respiratory rate- 22/min

Blood pressure- 150/70mm Hg

SpO2 at room air- 90%

GRBS - 120mg/dl

SYSTEMIC EXAMINATION:

CVS - S1 S2 present, no murmurs

RS -  pleuritic rub heard

P/A - 

Shape of Abdomen - scaphoid

No tenderness

No palpable mass

CNS - NAD

INVESTIGATIONS :

Rapid Antigen Test for Covid - negative

ABG at 3 AM on 19/10/21:

pH - 7.44

pCO2 - 38.2

HCO3 - 25

pO2 - 57.2

Hemogram:

Hb- 12.7 g/dl

TLC - 22,400

N/L/E - 63/32/02

PLC - 2.45 lakhs

RFT :

Urea - 39

Creatinine- 1.2

Na - 132

K - 3.9

Cl- 92

LFT :

TB - 1.3

DB - 0.5

AST - 28

ALT - 12

ALP - 136

TP - 6

A/G - 0.7

RBS - 118mg/dl

Chest xray