50 year old female with SOB
25th November ,2020
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Case presentation:
A 50 yr old Women came to casualty on 24-11-2020 at around 4pm with c/o of SOB and cough since 2hrs
who was normal till day before yesterday night .. suddenly developed
SOB-not associated with chest pain and palpitations
for which she was taken to RMP ..some medication and O2 inhalation given (medication no records) ..her SOB was relieved followed which she was asymptomatic till 4 pm in the evening..then again she developed SOB ,then she was brought to our hospital for further evaluation.
No H/O palpitations , chest pain , syncopal attacks ,
Fever , cold , burning micturition, constipation , diarrhoea ,orthopnea , PND
She is a k/C/O HTN , DM since 10yrs and on regular medications
PAST HISTORY-
10 years back she had similar episode for which for angio has been done
k/c/o dm,htn since 10yrs on regular medications of
Tab Metformin 1000mg + Glimiperide 2mg( gluconorm G2 forte) tab teneligliptin 20 mg
Tab Atorvastatin 20mg
Tab clopidogrel 75mg
Tab pregabalin and nortript( pragabalin NT)
PERSONAL HISTORY-
diet- mixed
appetite - normal
sleep - adequate
bowel and bladder - regular
No Addictions
ON GENERAL EXAMINATION -
Pt is Conscious, coherent , cooperative
No sign pallor , icterus, cyanosis, clubbing, lymphedenopathy , edema
VITALS-
Temperature- 98.4 F
pulse - 90bpm
RR - 18cpm
BP- 130/90 mmHg
Spo2 - 96%
GRBS -86 mg/dl
RESPIRATORY SYSTEM-
BEA+
coarse crepts B/L in all areas
CVS-
S1 S2 heard in no murmurs
Per Abdomen-
soft , non tender, no organomegaly
CNS-
No focal neurological deficits
INVESTIGATIONS DONE-
HAEMOGRAM
RFT
TROPONIN I
ECG
Chest X Ray
CT chest
CT chest done : 2.6 x 2.6 nodule noted in the left lower lobe with irregular margins with B/L pleural effusion R>L ...with CORADS 1
PROVISIONAL DIAGNOSIS-
SOB under evaluation
Anterior Wall MI ( LAD territory)
B/L mild pleural effusion
Hypoalbuminemia and hypokalemia
TREATMENT GIVEN-
Tab ecosprin 150mg OD
Tab clopitab 75mg OD
Tab Atorva 40 mg BD
Tab Met XL 25mg BD
Tab Pan 40 mg
Inj lasix followed by dytor 10mg
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