53 Year old male with SOB


Arushi Kumari 
Roll no. 15

Chief complaints:
A 53 year old male ,labourer by occupation came with complaints of shortness of breath since 1 day and cough since 1 day

HOPI:
Patient was assymptomatic 2 years ago and then Developed neck pain for which he visited local hospital and was diagnosed as having hypertension and using T.Telmisartan 40mg+ T.Metapropol 50mg since then,and asymptomatic 7 days ago and then developed low grade fever and associated with chills and rigors for which they took the consultation and used injections (unknown)and his fever got subsided,and after that developed generalised weakness for which he was tested and was told to be having Typhoid positive and got treatment symptomatically for 4 days and then after 4 days ,his weakness got subsided and got his investigations done and tested positive for Dengue antibody(IgG positive)and since 23/08/2022 night developed dry cough and shortness of breath at rest,and brought here for further management

Personal history:
Mixed diet
Normal Apetite 
Chronic alcoholic 90ml/day ,since 20years
Chronic smoker since 20 years.
On admission: 
Pt is consious and oriented 
Bp:130/100mmhg
Pulse rate:120bpm
Respiratory rate:40cpm
Spo2:62% on Room air
GRBS:151mg/dL
Respiratory system:
Bilateral air entry present
Bilateral basal crepts+

Past History :
Not a known case of Diabetes, Asthma , CAD, Epilepsy 
Known case of HTN sincw 2 years and was on regular medication .

Personal History :
Diet : 
Appetite: normal
Sleep: adequate
Micturition : normal 
Bowel: regular
Addiction: Alcoholic since 15 years                                ( stopped now )
                  Bidi sice 15 years ( now                                  ocassionally )

Family History :
Not significant 

General Examination:
Patient is conscious , coherent and cooperative .
No Pallor 
No icterus 
No cyanosis 
No clubbing 
No lymphandenopathy 
No edema
Afebrile 
PR: 104bpm
RR: 31cpm
BP: 130/100 mmHg 

Systemic Examination :
CVS : S1S2 heard 
RS: BAE+, clear
P/A: soft. non-tender 
CNS: NAD





Investigations :
24/08/22 
25/08/22

Plan of Care :
- IV fluid NS 10mL 
Z- Inj. Monocef 1gm IV/BD
-  Inj. Pan 40mg IV/OD
- Inj. Neomol 1gm IV/SOS ( if temp.more        than 101F)
- Tab. Dolo 650mg TID 
- Tab. Doxy 100mg PO/BD
- Nebulization with Duolin and Budecort 8th     hourly 
- GRBS monitoring 6th hourly 
- Monotor Vitals 

Provisinal Diagnosis :
Viral Pneumonia with severe ARDS 

My orientation around this case: 
1. What is the reason of SOB in this patient? 
Ans. Deranged ABG
2. What is the reason of fatty liver in this patient? 
Ans. Patient was chronic alcoholic










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