General medicine ICU patient
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A 80yrs old female patient from nalgonda housewife by occupation came to hospital with chief complaints of-
1.fever since 3 days
2.pain in abdomen on and off since one month
3.burning micturition since 1 month
History of presenting illness:
Patient was apparently asymptomatic one month back then she developed pain in abdomen which was diffuse,non radiating associated with burning micturition,then she started having fever since 3 days which is high grade not associated with cough,cold and headache
History of past illness:
H/o # ?rt neck of femur fracture 4yrs back since then she managed to walk with walker
H/o #? Lt knee fracture 2yrs back since then she was bed ridden
Not a k/c/o of DM,HTN, epilepsy,asthma.
Treatment history:
No treatment history
Personal history:
Diet:mixed
Appetite:normal
Sleep : normal
Bowel and bladder: irregular
Micturition: burning
H/o no addiction
Family history: not significant
GENERAL EXAMINATION:
No pallor
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals:
Temperature: 103F
pulse rate: 102 bpm
Respiratory rate:20cpm
bp:130/80mmHg
GRBS:123mg%
Systemic examination:
Cvs:
S1 s2 heard no murmer
Respiratory:
No dyspnoea no wheeze position of trachea centre
Vesicular breath sound heard
Abdomen:
shape of abdomen obese, diffuse tenderness present
CNS:
level of consciousness drowsy
Speech normal
Provisional diagnosis :
Community acquired pneumonia
Renal calculi
Mild hydrocephalus
Investigations:
USG REPORT
ANTI HCV ANTIBODIES
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