55 year old lady with Grade IV SOB, cold and fever.
A 55 year old woman who is a housewife by occupation was brought to the casualty with the chief complains of -
1. Fever since 7 days
2. Cold since 1 day
3. SOB since 30 mins
History of present illness: Patient was apparently asymptomatic 7 days ago when she developed Low grade fever which was associated with cold.
C/O SOB since 30 mins (Grade IV)
Not associated with chest pain, giddiness, sweating.
H/o palpitations since 5 days.
H/o fever and toothache 7 days ago which lasted for 1 day and subsided.
H/o cold since 1 day
H/o cough with sputum since 1 day which is white in colour.
No h/o nausea, vomiting, loose stools.
No h/o decreased urine output.
No h/o burning micturition, pedal Edema.
No h/o rashes.
Past h/o:
K/C/O DM and Hypertension since 2 years.
On TAB. MET XL 25mg, TAB. ECOSPRIN 150mg, TAB. CLOPITAB 70mg, TAB. ROSOVAS 20mg and
TAB. PROLOMET XL 25mg PO OD.
Family history: Not significant
Personal history:
Diet- Mixed
Appetite- Normal
Sleep- Adequate
Bowel and Bladder movements- regular
No addictions.
No known drug allergies.
General examination:
She is conscious, coherent, cooperative, well oriented to time, place and person. She is moderately built and moderately nourished.
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Edema- absent
Vitals on admission-
Temperature - 99.2 F
PR- 93 bpm
BP- 130/90 mm Hg
RR- 16 cpm
SpO2- 98% on RA
Systemic examination:
CVS- S1,S2 sounds heard. No murmurs.
RS- BAE present, Fine crepitations + in b/l lungs in Mammary areas.
P/A- Soft, non tender, Bowel sounds heard
CNS- NAD
PROVISIONAL DIAGNOSIS:
? HEART FAILURE with ACUTE PULMONARY EDEMA
? Bronchopneumonia
With K/C/O TYPE II DM AND HTN.
Clinical images :
Nutritional phenotype
Pallor :
Loose teeth :
CBP :
Ultrasound report :
Treatment given :
1) INJ. LASIX 40 mg IV BD
2) TAB. ECOSPRIN 150 mg PO OD
3) TAB. CLOPITAB 75 mg PO OD
4) TAB. MET XL 25 mg PO OD
5) INJ. NEOMOL IV SOS
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