40 year old male with sob


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

G Aishwarya
Roll no:35

A 40 year old male, tea seller by occupation ,came to OPD with chief complaints of 
Shortness of breath since 1 and half month 
chest discomfort since 1 and half month

HOPI: Patient was apparently normal 1  and half month back ,starts his day with 90ml of whisky and then goes to sleep and wakes up for lunch and then takes rest till evening . Starts his tea stall by the evening and works overnight on highway.
One night, he spent all his night in rain following next day he developed fever ,cold and mild cough . Initially he used tab.DOLO 650 mg ,then as fever and cold were not subsided ,went to hospital and diagnosed with covid 19 .
 Since then patient has SOB grade 2 which was progressed to grade 3 in few days and then he was diagnosed with hypertension.
Now presented with SOB grade 3.

No H/O chest pain ,palpation, giddiness

Takes alcohol regularly ( 90 ml of whiskey daily) since 4 years
H/O smoking since 25 years regularly (5-6 cigarettes per day)

Past history:
H/O hypertension since 1 and half month
No H/O diabetes , thyroid, asthma, epilepsy, cardiovascular diseases

No H/O  any allergies
 
Treatment history:
Patient was on following medications after diagnosis
Tab.CLINIDIPNE 10 mg OD
Tab.DYTOR 5mg OD
Tab. ISOSORBIDE +HYDRALAZINE 20/37.5 mgOD
Tab. NICARDIA 10 mg OD
Tab. MET XL 50 mg OD
Tab. FORACORT inh. BD

General examination:
Patient is conscious,coherent and cooperative 

Moderately nourished and built

No signs of pallor, icterus,clubbing, cyanosis, lymphadenopathy,edema

Vitals:
Temp : afebrile
PR:82bpm
RR: 20 cpm
BP: 130/70 mmHg
Spo2: 98%at RA



Systemic examination:
Respiratory system: decreased breath sounds, creptations heard


CVS: S1,S2 heard , no murmurs
P/A: soft,non tender, bowel sounds heard
CVS: normal

CBP:
Hb- 15.8
Wbc- 8400
N/L/E/M- 50/39/4/7
Plt- 3.1 lakhs

CUE: within normal range

LFT:
TB: 0.86
DB: 0.24
AST: 44
ALT: 65
ALP:212
TP: 7.2
Albumin: 4.5
A/G ratio: 1.67

RFT:
Blood urea: 29
Sr.creat: 0.9
Na: 142
K :4
Cl: 102
Diagnosis:
UNCONTROLLED HYPERTENSION, HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF-58%), GRADE 1 HYPERTENSIVE RETINOPATHY CHANGES.

Treatment:

1.Tab. AMLODIPONE 5mg/ PO/ BD
2.Tab. TELMA 40mg/PO/OD
3.Tab. PANTOP 40mg PO/OD
4.Syp.SUCRALFATE 15ml PO/TID

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