61 Y/M with cough ,sob and foreign body sensation

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan   

18 - 09-2022

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

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

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