Case of SOB

 CHIEF COMPLAINTS 

Pt came to casuality with chief complaints of
• cough since 5 days
• SOB since yesterday evening
• Foreign body sensation in the throat since yesterday

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 3 months back then then he had weakness of bilateral lower limbs which was sudden in onset for which he consulted doctor and diagnosed have having low potassium and given medication and now pt is unable to walk without stand

Now pt having cough since 5days which is dry type for 4 days and associated with sputum since today morning which is yellowish white in colour non foul smelling , not blood stained and pt complaints of chest pain while coughing , and also epigastric pain

Decreased urination since 10days
Pt is having sob grade 3 since yesterday evening and also had foreign body sensation in throat since today morning
▪ H/ O fever

N/H/O  cold, chills , rigors, palpitations, nausea , vomiting, loose stools , no odonophagia, no dysphagia

K/C/O diabetes since 15 yrs and is on medication.

Past history

Had a surgery for appendicitis, 15 yrs back.

Not a known case of HTN, asthma, epilepsy, TB

Personal history

DIET- mixed

Appetite - decreased since 3 days

Sleep- adequate

Bowel and bladder movements - regular

Habits- used to consumes toddy 15 years back and stopped consuming since then

GENERAL EXAMINATION

Patient is conscious coherent cooperative, well oriented to time place person

Thin built and  nourished 

 Pallor-absent 

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent







VITALS at admission

 Bp - 100/70 mm hg

PR - 160 bpm

RR -30 com

SpO2 -92% 

GRBS - 150 mg/ dl

SYSTEMIC EXAMINATION

•CVS- S1, S2 heard

• RS- BAE  present and Bilateral crypts present

• CNS - intact

•PA- Soft , non tender 


INVESTIGATIONS

DAY 1 ADMISSION












PROVISIONAL DIAGNOSIS 

ANTERIOR WALL MI 

TREATMENT

1) INJ HEPARIN 5000 IU IV/ QID

2) INJ PAN 40 mg IV / OD

3) INJ ZOFER 4 mg IV / OD

4)INJ OPTINEURON 1 amp in 100 ml NS 

IV/OD

5)TAB ECOSPRIN AV (75/20) PO/HS

6)TAB CLOPIDOGREL 75 mg PO/ HS

7)TAB MUCOMIX 550 mg PO/OD

8)MONITOR VITALS AND GRBS

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