A 58years old male patient with chief complaint of Shortness of breath

This is an 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 patient's 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 the comment box.

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

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