GM short case
65 years old female come with a complaintof fever since 1 week
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65 year female ,resident of miryalguda ,home maker came to casualty with
C/o-
Fever since 1 week
HOPI-
Patient was Apparently asymptomatic 1 week back .
Then she developed fever which is high grade ,sudden in onset & associated with chills.
A day later ,she developed shortness of breath.
Daily routine:-
Patient generally wakes up at 6am and takes tea and rice.
Then she knits for sometime and takes rice for lunch and dinner.
No h/o Loose stools, vomitings,
No h/o Hematuria, dark stools.
No h/o pain abdomen.
PAST HISTORY:-
K/c/o
Diabetes since 20 years
HTN since 20 years
No past history of allergies or surgeries.
No H/o TB in the past
PERSONAL HISTORY:-
diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movement- normal
Micturition - normal
(No burning sensation no
Addictions:-
Patient takes alcohol - 90ml 2-3 times a week.
toddy - 1 full glass ,2-3 times a week
no h/o smoking.
FAMILY HISTORY:-
>No relevent family history.
DRUG HISTORY:-
Patient takes tablets for diabetes
Atorvastatin 100mg
Glimipide
Metformin
GENERAL EXAMINATION:-
Patient was conscious, coherent, cooperative,well oriented to time place and person.
Moderately built & moderately nourished.
No pallor,
No Icterus,
No cyanosis,
No Generalised lymphadenopathy,
No clubbing,
No Bilateral pedal edema
Vitals:-
Temperature - Afebrile
BP -110/70mmhg
PR - 75 bpm
RR -18cpm
