80/M with shortness of breath

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


80 year old male , resident of Dhacharam ,  butcher by occupation came to the OP with c/o SOB since 15 days


History of presenting illness :


Patient was apparently asymptomatic 15 days back then he went for regular checkup to local hospital where he was told his sugar levels r high which were 350mg/dl  for which he didn't do anything and just continued his DM tablets .


 He experienced SOB which was insidious in onset and gradually progressed from grade 3 to grade 4  and was not associated with chest pain , excessive sweating , pedal edema  , decreased urine output or burning micturation.


C/o fever 15 days back sudden intermittent high grade releived on taking tab. Dolo 650mg TID no diural variation  for 5 days .


Pateint also experienced giddiness since 15 days


No h/o headache , blackouts and falls , ear pain , watering from eyes , photophobia , vomiting, LOC 


Past history :


K/c/o HTN  since 15  years on tab. Telma + hydrochlorothiazide po/or


K/c/o DM since 15 years and on tab. Glimi M1 po/bd .

 

No addictions 

Stopped eating nonveg since 2 months as he was told by doctors as his sugar levels were not in control .


Personal history :

Sleep : adequate 

Diet : mixed 

Appetite : normal 

Bowel and bladder : regular 

Addictions : none 


General examination:


Pt is c/c/c 

No pallor , icterus , cyanosis, clubbing, lympadenopathy, edema 


Vitals : 

PR: 86 bpm

RR: 18cpm

BP: 130/80 mmHg

GRBS : 146 mg/dl 


Systemic examination : 

CVS :  S1 s2 heard no murmurs

RS : BAE NVBS heard

P/A : epigastric tenderness present 

No free fluid.

CNS : No FND







Investigations :




X-Ray chest :



Ultrasound :


2D echo :



Treatment :

Inj. CLEXANE 40 mg SC/OD
Tab. TELMA-H PO/OD
Tab. GLIMI-M1 PO/BD
Tab. NEUROBION FORTE PO/BD 


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