60 year-old lady with SOB on exertion and productive cough

A 60 year-old lady hailing from Chintapally came to the hospital with the chief complaints of shortness of breath on exertion since 1 month, cough with expectoration since 3-4 days.

History of present illness: 

Patient was apparently asymptomatic 1 month ago when she developed shortness of breath. 

C/O SOB on exertion since 1 month (Grade II) 

C/O cough with expectoration since 3-4 days a/w generalized weakness. 

Not associated with chest pain, giddiness, sweating. 

No h/o Palpitations. 

No h/o fever, cold, sore throat, night sweats, no h/o loss of appetite. 

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: 

No history of Diabetes Mellitus, Hypertension, Tuberculosis, Bronchial Asthma, CVA, CAD. 

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 - 97.2 F

PR- 80 bpm

BP- 120/80 mm Hg

RR- 22cpm

SpO2- 99% on RA

Systemic examination:

CVS- S1,S2 sounds heard. No murmurs.

RS- BAE present, trachea is central, no wheeze.

P/A- Soft, non tender, Bowel sounds heard

CNS- NAD

PROVISIONAL DIAGNOSIS:

ANAEMIA UNDER EVALUATION 

SECONDARY TO CKD. 

Investigations :

TREATMENT :

 - INJ. OPTINEURON 1 amp in 100ml NS/IV/OD

- INJ. PAN 40 mg IV/OD