A 40 year old male with sob and cough
NAME:-A.Vishal
Roll no:- 148
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I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
A 40 yr old male came to the opd with
cheif complaints of :-
(1)B/L lower limb swelling since 20 days.
(2)Generalised Swelling of the body since 15 days.
(3)SOB since 10 days.
HOPI:-Patient was apparently asymptomatic
no h/o burning mircturition
no h/o decrease in frequency of micturition
no h/o fever, nausea, vomiting ,pain abdomen
past history :-
Hypertension since 3years and on regular medication
not a known case of Tb,bronchial asthma ,CAD,Diabetes
personal history :-
Appetite normal
Diet mixed
sleep inadeqauate
bowel and bladder ireegular
Addictions - Alcohol ocasionaly
Family history:-
no similar complaints in family
General examination:-
Patient is consious ,coherent ,coopertaive
well oriented to Time place person
vitals :-
Temperature :- 98.4 f
pulse :- 102bpm
Respirtaory rate :- 20cpm
Bp :- 130/70 mmhg
spo2 98% on 6L of o2
Grbs 126mg%
Systemic examination :-
cvs :- s1, s2 heard ,no murmurs
Respiratory :- Dyspnea present
position of trachea :- central
breath sounds :- vesicular
crepts are present
Abdomen :-
soft ,non tender
CNS:-
NAD
PROVISONAL DIAGNOSIS
pulomary edema secondray toacute left ventricular failure, anemia secondray to renal failure with hypertension
Investigations:-
25-01-2022.
Treatment :-
1)Head end elevation
2)o2 inhalation to maintain spo2 >94%
3)Inj .lasix 40mg iv bd
4)Inj . pantop 40mg iv od
5)Inj.zofer 4mg sos
6) Inj .TRENEXA 500 mg iv stat
7)Inj.AMOXICLAV 1.2gm iv bd
8)Nebulization with budecort Tid, Ipraeent qid
9) montec lc po/od
10) syr. Ascoril po/tid
