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(20-11-2022)
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
