A 61 year old male patient with cough and 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 patients clinical problems with collective current based inputs.

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 today morning

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
▪No H/ O fever, cold, chills , rigors, palpitations, nausea , vomiting, loose stools , no odonophagia, no dysphagia

DAILY ROUTINE

15 years back pt used to wake up at 5:am in the morning and does his daily routines and takes breakfast at 7:00 and goes to work ( toddy collector) and takes lunch at 1:00pm and again goes to work and returns home at 5:00 pm in evening and takes dinner by 8:00 pm and goes to sleep by 10:00 pm
• Then he had surgery ( appendicitis) 15 years back since then he stopped working as toddy collector and started working as farmer for 15 years
• Now since 3 months he stopped working as farmer because of his bilateral lower limb weakness
• Now he wakes up at 7:00 am does his daily routine takes breakfast and stays at home and take dinner at 8:00 pm and goes to sleep by 10:00pm

PAST HISTORY

Known case of diabetes since 15 years ( and on regular medication - GLICLAZ- M 1/2 tablet daily)

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

 FAMILY HISTORY 

not significant

GENERAL EXAMINATION

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

Thinly 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

DAY 2 OF 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