A 54 year male patient with Acute heart failure

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A 54 year old male patient who's labour by occupation came to casualty with chief complaint of SOB since 4 months and its increased since 4 days.

K/c/o  orthopnea.

K/c/o PND( Paroxysmal nocturnal dysopnea)

History of present illness:

Patient was apparently asymptomatic 15 years back and then he found to have hypertension on his regular checkup 8 years ago. 

H/o CVA involving left upper and lower limbs weakness and deviation of mouth to left and that's resolved after 1 month.

5 years ago he diagnosed with DM ,but on IRREGULAR MEDICATION.

In March,with pedal edema patient came to hospital and he was told to have Hypothyroidism and hypercholesterolemia(BUT NOT ON MEDICATION).

1 month ago C/O lower backache diagnosed with renal calculi 7 mm and used medication.

Since 4 weeks c/o sob and it has increased more since 5 days associated with orthopnea PND.

Past history:

Patient is not a known case of epilepsy, tuberculosis and asthma.

Personal history:

Diet : mixed

Sleep: adequate

Appetite: normal

Bowel and bladder movements : regular

Habits : occasionally Alcoholic

Drug history: 

Patient is on diabetic medication ( irregular)

Patient is on renal calculi medication

Not allergic to any known drugs.

Family history:

No significant complaints in family 

General examination:

Patient was coherent, cooperative and conscious.

No history of pallor, icterus, cyanosis,no clubbing,no lymphadenopathy, edema

Vitals:

Temperature:- afebrile

SpO2:-93% at room air

Pulse rate:- 72/ min

Respiratory rate:-26/min

Bp:-140/100 mm Hg

Systemic examination:

CARDIOVASCULAR SYSTEM: 

S1 and S2 sounds are heard

RESPIRATORY SYSTEM:

Postion of trachea is central

Bilateral air entry- positive

IAA crepts -positive 

ABDOMEN:

Abdomen is soft and tender.

No palpable mass 

CENTRAL NERVOUS SYSTEM:

Patient is conscious

Speech - Normal 

No neurological deficits.

Investigations:

Provisional diagnosis : 

Acute cardiac failure secondary to CAD .Acute anterior wall MI

Treatment plan:

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.