ICU bed 6 
54yr /M
A 54 yr old male labourer by occupation , came to the the casualty with chief complaints of SOB grade since 4 months  increased since 4 days from grade 2 to 3,and c/o orthopnea and PND
patient was apparently alright 15 yrs back and found to have hypertension on regular check up 
8 yrs ago H/O CVA involving left upper and lower limbs  weakness and deviation of mouth to left (? infarct) -resolved after 1 month 
5 yrs ago diagnosed with DM, but on irregular medication 
March 2021 -C/O B/L pedal edema -patient came to the hospital and was told to have hypothyroidism and hypercholestrolemia ( but patient did not use any medication) 
1 month ago-C/O  LBA - diagnosed with renal calculi 7 mm and used medication 
since 4 weeks C/O SOB grade 2 to 3 ,and progressed to geade 4 since 4 days associated with orthopnea,PND ,no H/O fever pedal edema 
K/C/O HTN(15 yrs) ,DM (5yrs) ,Hypothyroid 
personal history
appetite-normal
bowel movements-regular
micturition -normal 
addictions-occasional
no significant family history
general examination
no pallor,icterus,cyanosis ,clubbing, lymphadenopathy,edema
tepm-98.6F
pulse-72bpm
respiration -26/min
BP left- 140/100 mmhg 
Spo2- 93%
GRBS-146 mg/dl
CVS-S1,S2 heard
RS-BAE+,B/L IAA crepts + 
ABDOMEN - soft,and non tender
CNS- NAD
provisional diagnosis:
Acute heart failure secondary to CAD (coronary artery disease) ,? acute anterior wall MI 
Treatment
1) Tab.Ecosprin 325 mg/po/stat
2) Tab.Clopitab 300 mg /po/stat
3) Tab.Atrovastatin 80 mg /po /stat
4)inj.lasix 40 mg Iv /BD
5) Neb.DUOLIN stat,budecort stat
6) inj.pantop 40 mg IV OD
7)Tab.telma 40 mg po/OD
8) Tab.Thyroxine 25 ug po/OD
9) inj.CLEXANE 60 mg s.c /BD
10) Tab. Clopitab A 150 mg po/OD
11) Tab.MET -XL 12.5 mg/po/OD
12)O2 inhalation (2 lit)
13) GRBS 6 th hourly monitoring
14) strict I/O charting

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