Case Study 2
September 10, 2021
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September 10, 2021
A 56 year old man driver by occupation presented to OPD with shortness of breath
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 year back , then he had shortness of breath with chest pain 6 months back. He used medication for 3 months and then he discontinued later.
PAST HISTORY
He was diagnosed to be hypertensive and diabetic 1 year back.
He's on regular medication T.Glimi 500mg for diabetes and no regular medication for hypertension.
PERSONAL HISTORY
Appetite is normal and on mixed diet with regular Bowel and bladder movement and adequate sleep.
He's also chronic smoker since 20 years and also occasional alcoholic.
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
Patient was conscious, coherent and cooperative
Pulse rate: 92 bpm
Blood pressure: 120/70 mmHg
Respiratory Rate: 26 cpm
SpO2: At room air - 76% , 98% with 16L of O2
SYSTEMIC EXAMINATION
CVS:
Apex beat : 5th ICS
RESPIRATORY:
Dyspnea
PER ABDOMEN:
Obese, tenderness absent, Bowel sounds heard
CNS:
Normal
PROVISIONAL DIAGNOSIS
Acute Pulmonary edema
INVESTIGATIONS
ECG:
Hemoglobin - 15.9
TLC - 17,500
Platelets - 2.45
TREATMENT
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