58 year old male with SOB

58yr/Male with c/o SOB

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Chief Complaints:Shortness of breath since morning

History of Present Illness:

       Patient is apparently asymptomatic 5yrs back then he developed right side hemiplegia for which he took medication and also diagnosed to have type 2 diabetes mellitus and also hypertension after 3yrs he was operated for hernia

After 1yr he had severe back pain,went to hospital,Xray was done and diagnosed with AKI on CKD with emphysematous pyelonephritis underwent 3 sessions of hemodialysis today he developed SOB which was insidious in onset, gradually progressive,orthopnea present

History of Past illness:

       H/o-DM from past 3yrs

       H/o-Hypertension

No h/o-TB,Asthma, Epilepsy, Leprosy,CVA,CAD,Cyanosis,pedal edema, clubbing, lymphadenopathy

Personal History:

    Married

Diet-mixed

Appetite-normal

Bowel movement-Regular

Micturition-normal

Addictions- No

Family History:

No history of DM, CAD, Asthma and thyroid disorders in the family

General Examination:

Vitals:

Temp:Afibrile

Respiratory rate:34bpm

Pulse:111 bpm

Blood pressure:160/100mmhg

Sp O2 :97

Systemic Examination:

Cardiovascular Examination:

Thrills:no

Cardiac sounds:S1,S2 heard

Cardiac murmurs:no

Respiratory system:

Dysponea:yes

Wheeze:no

Position of trachea: central

Breath sounds: vesicular

Adventitious sounds:

Abdomen

Shape of abdomen: Scaphoid

Tenderness:no

Palpable mass:no

Henias orifices: normal

Free fluid:no

Bruits:no

 

Liver:Not palpable

Spleen:not palpable

Bowel sounds:yes

Central Nervous system:

 Pt is conscious

Speech: normal

Signs of meningitis:no

Cranial nerves:normal

Motor and sensory system:normal

Diagnosis:

-CKD

-Cardiogenic pulmonary oedema secondary to anterior wall of myocardial infarction

-Right side hemiparesis

Investigation:

ECG(16-11-2022)

ECG(18-11-2022)

ECG(19-11-2022)

ECG(20-11-2022)

ECG(21-11-2022)

Treatment:

Inj.piptaz 2.25mg IV/TID-2days

Tab.LASIX 40mg po/bd-1week

Tab.LEVIPIL 509mg po/bd-1week

T.NICARDIA 10mg po/tid

T.OROFER XT PO/OD

T.NODOSIS 599mg IV/BD

T.SHELCAL XT PO/OD

T.ECOSPIRIN AV PO/HS