CASE 16 70F WITH SUDDEN ONSET SOB

Doa 24/12/24

Dod 26:12/24

Diagnosis

HF WITH PEF

BRONCHIAL ASTHMA SINCE 2 YRS

UNCONTROLLED SUGARS ( DM II ) SECONDARY TO DRUG INCOMPLIANCE

DENOVO HYPERTENSION

Case History and Clinical Findings

C/O SOB SINCE 2 MONTHS

HOPI-

PT IS APPARENTLY NORMAL 2 MONTHS ,SUDDENLY HAD SHORTNESS OF

BREATH,GRADUAL IN ONSET A/W EXERTION(GRADE III NYHA),PND +,ORTHOPNEA

NO H/O FEVER,COUGH,COLD,VOMITINGS,DIARRHOEA,BURNING MICTURITION

K/C/O DM II SINCE 3 MONTHS NOMEDICATION TAKEN

NO H/O HTN,ASTHMA,CAD,THYROID DISORDERS

PERSONAL HISTORY

APPETITE NORMAL

BOWEL &BLADDERNORMAL

ADDICTIONS -NO

GENERAL EXAMINATION

PT IS C/C/C

AFEBRILE

PR 101BPM

BP 160/100MMHG

GRBS 272MG/DL

CVS S1S2 + NO MURMURS

RS BLAE + NVBS

CNS NFND

P/A SOFT NON TENDER

Investigation

RFT 24-12-2024 UREA 30 mg/dlCREATININE 0.8 mg/dl URIC ACID 3.0 mmol/LCALCIUM 9.9 mg/dl

PHOSPHOROUS 2.4 mg/dl SODIUM 137 mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 99 mmol/L

LIVER FUNCTION TEST (LFT) 24-12-2024 Total Bilurubin 0.67 mg/dlDirect Bilurubin 0.18

mg/dlSGOT(AST) 33 IU/L SGPT(ALT) 34 IU/L ALKALINE PHOSPHATASE 255 IU/LTOTAL

PROTEINS 6.9 gm/dl ALBUMIN 4.27 gm/dl A/G RATIO 1.62

COMPLETE URINE EXAMINATION (CUE) 24-12-2024 COLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR ++++BILE SALTS NilBILE

PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS

NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Anti HCV Antibodies - RAPID 24-12-2024 Non ReactiveHBsAg-RAPID 24-12-2024 Negative

HEMOGRAM

HB 12.1 TC 9,700 PCV 35.2 RBC 4.15 PLATELET COUNT 2.61

N/L/E/M/B 50/40/03/07/00

FBS 175 mg/dl POST LUNCH BLOOD SUGAR 24-12-2024 258 mg/dl HBA1C 6.6

ABG 25-12-2024 10:26:AMPH 7.40PCO2 39.1PO2 55.4HCO3 23.8St.HCO3 24.0BEB -0.3BEecf -

0.4TCO2 47.7O2 Sat 87.3O2 Count 15.7

2D ECHO WAS DONE ON 24/12/24

MILD TR WITH PAH,MILD MR,MILD AR

NO RMWA NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTIONS,NO LV CLOT

Treatment Given(Enter only Generic Name)

INJ HAI SC/TID ACC TO GRBS

TAB TELMA 40MG PO/OD/7AM

TAB GLIMI MA PO/BD

TAB PAN 40MG PO/OD/7AM

TAB LASIX 20MG PO/BD

TAB MET XL 25MG/PO/OD/9PM

TAB LEVOCITRINE 10MG PO/HS/9PM

TAB ECOSPIRIN AV 75/10 PO/HS/9PM

TAB GABAPIN NT PO/HS/9PM

NEB WITH BUDECORT,IPRAVENT 8TH HOURLY

Advice at Discharge

INJ HAI SC/TID ACC TO GRBS

TAB TELMA 40MG PO/OD/7AM

TAB GLIMI MA PO/BD

TAB PAN 40MG PO/OD/7AM

TAB LASIX 20MG PO/BD

TAB MET XL 25MG/PO/OD/9PM

TAB LEVOCITRINE 10MG PO/HS/9PM

TAB ECOSPIRIN AV 75/10 PO/HS/9PM

TAB GABAPIN NT PO/HS/9PM

TAB DERIPHYLLING RETARD 150MG

FORACORT ROTAHALER 200MCG 2 PUFFS TWICE DAILY

Follow Up In february 2025

FBS 110 mg/dl PLBS 158 mg/dl HBA1C 6.3