70 yrs old male patient came to the opd with the
chief complaints of
Sob since 6 days which was severe
pedal edema since 5 days
generalized weakness since 5 days
History Of Present Illness
Patient was apparently asymptomatic 7 months back then developed generalized weakness following which he developed sob which was mild 2 days following sob he developed pedal edema pitting type then contipation for which he went to local doctor and was treated
6 days back he developed sob which was insidious in onset abd progressed to interfere his daily activities and sleep
Patient has history of PND
7 months back Reports
2 D echo
Past History
Nog history of DM HTN CAD ASTHMA TB
Personal History
married
normal appetite
mixed diet
bowels regular
micturation normal
no allergies
habits
alcohol from past 50 years occasional consumer
Stopped 4 years back
Smoking BD from past 50 years 1 or 2 per day
On Examination
Pallor No
Ictrus No
Cyanisis No
Kolionychia No
Lymphedenopathy No
Edema Present
Pitting type
SYSTEMIC EXAMINATION
Cvs
S1 s2 heard no murmurs
Respiratory system
Normal vesicular breath sounds, no wheeze , no dyspnea , trachea is central
Abdomen
Shape of abd - obese
No tenderness
No palpable mass, fluid , bruit
No palpable liver , spleen
P/V , P/R
CNS
conscious
response to speech
no focal deficits
no meningeal signs
no cerebral signs
Investigation
RBS 188
Treatment
day 1
1 Injection lasix 40 mg IV/BD
Tab pan 40 mg PO/OD
Tab aldactone 25 mg PO/OD
Inj Thiamine 1 amp in 100ml IV /BD
Tab Ramipril 2.5 mg PO/OD
Tab Met xl 12.5 mg PO/OD
Day 2
1 Injection lasix 40 mg IV/BD
Tab pan 40 mg PO/OD
Tab aldactone 25 mg PO/OD
Inj Thiamine 1 amp in 100ml IV /BD
Tab Ramipril 2.5 mg PO/OD
Tab Met xl 12.5 mg PO/OD
Discharge summary:
Expected date of discharge:
Diagnosis:
Chief complaints:
70 yrs old male patient came to the opd with the chief complaints of
Sob since 6 days which was severe
pedal edema since 5 days
generalized weakness since 5 days
History of present illness:
Patient was apparently asymptomatic 7 months back then developed generalized weakness following which he developed sob which was mild 2 days following sob he developed pedal edema pitting type then contipation for which he went to local doctor and was treated
6 days back he developed sob which was insidious in onset abd progressed to interfere his daily activities and sleep
Patient has history of PND
Past History:
Nog history of DM HTN CAD ASTHMA TB
Personal history:
married
normal appetite
mixed diet
bowels regular
micturation normal
no allergies
habits
- alcohol from past 50 years occasional consumer
Stopped 4 years back
- Smoking BD from past 50 years 1 or 2 per day
General examination:
Patient is conscious, coherent, co-operative, oriented to time, place and person.
No pallor, icterus, cyanosis, clubbing, Kolionychia, lymphadenopathy, edema
Vitals:
Afebrile
PR - 84 bpm
BP - 110/70 mm Hg
RR - 16 cpm
SpO2 - 96% at room air
Systemic examination:
Cvs
S1 s2 heard no murmurs
Respiratory system
Normal vesicular breath sounds, no wheeze , no dyspnea , trachea is central
Abdomen
Shape of abd - obese
No tenderness
No palpable mass, fluid , bruit
No palpable liver , spleen
P/V , P/R
CNS
conscious
response to speech
no focal deficits
no meningeal signs
no cerebral signs
Treatment
Day 1
1.Injection lasix 40 mg IV/BD
2.Tab pan 40 mg PO/OD
3.Tab aldactone 25 mg PO/OD
4.Inj Thiamine 1 amp in 100ml IV /BD
5.Tab Ramipril 2.5 mg PO/OD
6.Tab Met xl 12.5 mg PO/OD
Day 2
1.1 Injection lasix 40 mg IV/BD
2.Tab pan 40 mg PO/OD
3.Tab aldactone 25 mg PO/OD
4.Inj Thiamine 1 amp in 100ml IV /BD
5.Tab Ramipril 2.5 mg PO/OD
6.Tab Met xl 12.5 mg PO/OD
