A 50 year old male came with c/o SOB since 1 hour,acute onset,grade 4,orthopnea +

HOPI-

The patient was apparently asymptomatic 6 years back then he developed SOB and went to a hospital where they performed 2D echo which showed heart failure with reduced ejection fraction(40%),he took the medicines for 1month and stopped as the SOB subsided

3 years ago, he had cough,breathlessness,fever and sputum for AFB is negative but was empirically started on ATT but used them only for 4 months and stopped,since then he had cough occasionally 

HISTORY OF PAST ILLNESS-

H/o inguinal hernia since 1 year(not operated)

K/c/o DM since 4 years on T.Glimy m1 BD

H/o old kochs -used ATT for 4 months,3 years ago

H/o HFrEF since 6 years secondary  to ?CAD

PERSONAL HISTORY-

Diet-mixed

Appetite-normal

Bowel and bladder-regular

Addictions-alcoholic since 30 years,consumes 90 ml daily

 And smokes 20 cigarettes/day since 30 years

FAMILY HISTORY-

No relevant family history

GENERAL EXAMINATION-

patient is conscious,coherent,cooperative 

no pallor,icterus,cyanosis,clubbing,lymphadenopathy and oedema of feet

Temp-98 F

PR-110/min

RR-40/min

BP-160/100 mmHg

SPO2- 94%

GRBS-124 mg%

SYSTEMIC EXAMINATION-

CVS-

S1,S2 heard

No murmurs and thrills

RESPIRATORY SYSTEM-

Dyspnea is present

Wheeze is present

Decreased BAE

Trachea is central in position

NVBS heard

ABDOMEN-

shape-obese




Liver and spleen-not palpable

Bowel sounds heard

No tenderness and palpable mass

PROVISIONAL DIAGNOSIS

SOB secondary to?HFrEF,?acute exacerbation of COPD

TYPE 2DM

INVESTIGATIONS-











Discharge summary-

Discharge Date
Date:20-6-21
Ward-:GENERAL MEDICINE
UNIT;-5
Name of Treating Faculty
DR.ARJUN
DR.HAREEN
DR.VAISHNAVI(PG Y2)
DR.CHANDANA(PGY1)
DR.KRUPA(INTERN)
DR.E.SAI NIKITHA(INTERN)
DR.SRAVANI(INTERN)
DR.TEJASWINI(INTERN)
DR.RAMYA(INTERN)
Diagnosis
HEART FAILURE WITH REDUCED EJECTION FRAACTION(EF 40%) SINCE 6 YEARS
DM II SINCE 6 YEARS
OLD KOCHS 3 YRS AGO
Case History and Clinical Findings
A 50 Yr old male came with complaints of SOB since 1 hour ,acute in onset, grade 4, orthopnea +,
History of chronic cough,since 2 years associated with whitish sputum ,no history of haemoptysis
No history of chest pain,palpitations,giddiness
NO history of vomitings,fever,loose stools

past History;-

History of inguinal hernia since 1 year (not operated)
K/C/O-DM since 4 yrs -on Tab Glimi M1 BD
H/O -Old kochs used ATT for 4 months -3 yrs ago
HFREF since 6 yrs secondary to ? CAD
GENERAL EXAMINATION:-
Patient is conscious ,coherent,cooperative,moderately built ,moderately nourished
N0 pallor,icterus,cyanosis,clubbing,koilonychia,lymphadenopathy.

VITALS:-
Temp-98 F
BP-160/100 mm hg
PR-110 bpm
RR-40 cpm
SPO2 at RA-94% and 98% on 2 L of oxygen
GRBS-124 mg/dl
SYSTENIC EXAMINATION :-
CVS -
S1 S2 heard,no murmurs
RSBAE
+,Dyspnoea +,wheeze +,
normal vesicular breath sounds
PER ABDOMEN
-No tenderness,no palpable mass
HERNIAL ORIFFICES -Hernia (present)
No Organomegaly
Bowel sounds heard
CNS- Normal

Name Value Range Name Value Range
BLOOD UREA 19-
06-2021 07:27:AM
46 mg/dl 42-12 mg/dl SERUM
CREATININE 19-06-
2021

1.7 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 19-06-2021 07:27:AM
SODIUM 136 mEq/L 145-136 mEq/L
POTASSIUM 4.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 105 mEq/L 98-107 mEq/L
COMPLETE BLOOD PICTURE (CBP) 19-06-2021 07:27:AM
HAEMOGLOBIN 16.0 gm/dl 17.0-13.0 gm/dl
TOTAL COUNT 9100 cells/cumm 10000-4000
cells/cumm
NEUTROPHILS 75 % 80-40 %
LYMPHOCYTES 16 % 40-20 %
EOSINOPHILS 03 % 6-1 %
MONOCYTES 06 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 1.20
SMEAR Normocytic
normochromic with
thrambocytopenia
COMPLETE URINE EXAMINATION (CUE) 19-06-2021

COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +++
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-5
EPITHELIAL CELLS 3-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
Treatment Given(Enter only Generic Name)
1) Nebulisation with duolin 6th hourly,budecort 6th hrly
2) INJ. Hydrocort 100mg IV stat
3)INJ Pan 40 mg IV OD
4) INJ .Human actrapid insulin acc to GRBS
8am -2 pm -8pm
5) GRBS 6th hrly
6) INJ .AUGMENTIN -1.2 gms IV BD

7) monitor vitals
Advice at Discharge
Inhaler FORMOMIDE 200mg 2 puffs BD. x 1 week
Tab LASIX 20 mg PO BD .
Tab GLIMI M 1 - PO BD .
Follow Up
REVIEW AFTER 2 WEEKS WITH FBS, PLBS, HBA1C
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY


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