35 yr old male with sob

E-LOGS GENERAL MEDICINE

 

Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.
A 35 yr old male patient , bar tender by occupation and chronic alcoholic came to casualty .


CHIEF COMPLAINTS : 
Shortness of breath since 10 days
Cough since 2 days 

HISTORY OF PRESENT ILLNESS : 
The patient was apparently asymptomatic 2 months ago . Then he started developing shortness of breath while lying down and on exertion. 
He also complained of chest pain .
They started visiting local rmp one month ago , where he was given injection? In each visit , After which Symptoms subsided for 10 to 15 days . 
After this , they visited a doctor and few investigations were done following which he was told to have a heart problem? 
Then the patient came to casualty  with complaints of 
SOB since 10 days .
The patient also gave history of cough since 2 days which was mucopurulent .

PAST HISTORY: 
no h/o DM
no h/o HTN 
no h/o allergies 

PERSONAL HISTORY: 
H/O alcohol consumption since 10 yrs 
H/O passive smoking since 10yrs at workplace 
Diet : normal
Appetite : normal
Bowel and bladder movements: normal 

FAMILY HISTORY:
no significant family history.


PHYSICAL EXAMINATION:
* Pallor-not seen
* Icterus-not seen
* Cyanosis-not seen
* Clubbing-not seen
* Lymphadenopathy-not seen
VITALS :
* temperature: afebrile 
* Pulse rate :140 - 160/ min 
* BP : 130/90
* Respiration rate : 30 /min 
* SpO2 : 98%
*GRBS : 132 mg%

SYSTEMIC EXAMINATION: 

1.CVS : 

*S1 and S2 heard

 2.RESPIRATORY SYSTEM:


     *BAE + , NVBS

3.ABDOMEN

     *Soft , NT

4.CNS:

     *NFND

PROVISIONAL DIAGNOSIS: alcoholic cardiomyopathy
Hfref secondary to cad 


INVESTIGATIONS : 


1.Inj. AMIODARONE 900mg in 32ml NS 

2.inj. AUGMENTIN 1.2gm IV /BD 

3 .tab . AZITHROMYCIN 500mg PO/OD 

4.inj.HYDROCORT 100mg IV /BD 

5.NEB DUOLIN  
    BUDECORT 8th hrly 

6.inj .LASIX 40mg IV /OD 

7. Inj . THIAMINE 200mg in 50ml NS 

8. Inj. OPTINEURON 1 ampoule in 50ml NS IV / OD 

9. FLUID RESTRICTION <1.5L per day 

10. SALT RESTRICTION <4gm per day .







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