70 year old female

70 year old female patient 


GM Blog: 70 year old female patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 30-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of fever since 20 days

Pain in abdomen and shortness of breath since 5days.

HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 20 days back then she developed fever which was high grade and intermittent type,associated with generalized body weakness,chills, she went to a rmp near by and took some medication which relieved the fever for 2 days and again fever get started she went to another hospital in miryalaguda where she was diagnosed with Dengue and treated but she developed pain abdomen and SOB for which she underwent an USG and diagnosed as ascites and was referred to our hospital

PAST HISTORY:

M/k/c/o hypertension, diabetes mellitus, tuberculosis, Asthma, thyroid disorders ,epilepsy or any other chronic illness 



PERSONAL HISTORY:
Moderately built and nourishment.
Diet: mixed. ( Non vegetarian)
Sleep- disturbed since few days
Appetite - reduced 
Bladder movement- normal
Bowel movements- reduced 
Allergy-no 
Addiction- Toddy occasionally ( few years back) 
Drug history- not significant 

FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
She is well oriented to time, place and person. 
She is moderately built and nourished  
Pallor - present 
icterus absent
No cyanosis
No clubbing
Pedal edema ( bilateral pedal oedema)
present 
No Lymphadenopathy 

Vitals on the day of admission 
Temperature - afebrile
Pulse rate - 82 bpm
Respiratory rate - 24 cpm
Blood pressure - 110/90 mmHg
SpO2 - 94% on Room air
GRBS - 92mg/dl

Systemic examination:

CVS:
Inspection:
Shape of chest: symmetrical 
No dilated veins
No visible pulsations 
Stretch marks present on the breast

Palpation: 
No pulsations
No dilated veins
Auscultation: s1 and s2 heard

CNS:intact

Per abdomen: soft ,tender,no organomegaly detected








Investigations:















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