78 YO/ MALAY/ FEMALE U/L 1) DM X3YEARS -ON T. METFORMIN 500MG BD 2) HPT X5-6 YEARS -ON T.

AMLODIPINE 5MG OD -ON T. PERINDOPRIL 4 MG BD 3) BZ X40 YEARS -ON MDI SALBUTAMOL 2 PUFFS PRN -ON MDI BUDOSENIDE 2 PUFFS BD -LAST ADMISSION FOR ASTMA IN 2007 -NO H/O OF INTUBATION\ 4) DYSLIPIDENMIA X2YEARS -ON T. LOVASTATRIN 20MG ON P/W 1) FEVER X2/7 A/W CHILLS AND RIGORS 2) COUGH X2/7 -WITH WHITISH SPUTUM -WITH RUNNING NOSE 3) SOB X2/7 -WORSENING ON ROUTINE HOUSEWORK -RELIEVED BY REST 4) A/W -MYALGIA -LETHARGY O/E ALERT, CONSCIOUS BP 142/72 HR 76 RR 20 T 37 SPO2 98 (UNDER RA) REFLO 8.3 THROAT MILDLY INJECTED LUNGS CREPITATIONS CVS S1SS2 P/A SNT, PARAUMBILICAL HERNIA LL NO PEDAL UPON DSICAHRGE, -PATIENT IS AFEBRILE -NO SOB -COUGH AND RUNNING NOSE DECREASING O/E ALERT, CONSCIOUS BP 100/60 HR 86 RR 20 T 37 SPO2 98 (UNDER RA) REFLO 7.3 THROAT MILDLY INJECTED LUNGS MINIMAL CREPITATIONS CVS S1S2 P/A SNT, PARAUMBILICAL HERNIA

LL NO PEDAL

CHEST X RAY: CARDIOMEGALY, MINIMAL HAZZINESS OVER RIGHT LOWER ZONE HB 11.6 TWDC 11.6 PLT 247 T. PROTEIN 75 ALBUMIN 31 GLOBULIN 44 T. BILIRUBIN 11 CALCIUM 1.98 PHOSPAHTES 1.98 MG 0.97 UREA 4.6 SODIUM 140 POTASSIUM 4.5 CREATININE 71 SPUTUM FEME CELL COUNT: < 25 POLYMORPH/ LOW POWER FIELD ORGANISMS: GRAM NEGATIVE COCCI 1+ PATIENT IS DISCAHRGED WITH -T. AUGMENTIN 635MG BD X5/7 -T. AMLODIPINE 5 MG OD -T. PERINDOPRIL 4 MG OD -T. LOVASTAIN 20MG ON -S/C ACTRAPID 6U TDS -MDI SALBUTAMOL 2 PUFFS PRN -MDI BUDOSONIDE 2 PUFFS BD DX CAP DIABETES MELLITUS HYPERTENSION BRONCHIAL ASTHMA DYSLIPIDEMIA