35 yr old male came to casualty with a complaint of Dry cough and shortness of breath.

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A 35 year male, driver by occupation, came with complaints of dry cough, grade II sob, nausea and with h/o hemoptysis.

History of presenting illness: 

A 35 year male with h/o dry cough, episode of hemoptysis, low grade fever, grade II sob (17/3/22), 

was admitted at yashodha hospital on 17/3/22 and diagnosed as:

- AKI on CKD - was dialysed 4times and advised for maintenance HD.

- LRTI - B/L non homogeneous opacities on xray - edema with superadded infections (on HRCT chest).

- Sepsis MODS.

then patient was discharged on 28/3/22.

CREATININE- 11   @admission

                          - 9   @discharge

USG - grade II RPD, CMD near complete lost, 

          - size - 9X3cm (Right)

                     - 8X3cm (Left)

2D ECHO- LV RWMA, EF:42%

Pt was asked to come for review after 1 week but pt didn't do due to personal reasons and came here for MHD.

presently c/o dry cough +, SOB grade II, Nausea +,

 hemoptysis  subsided.

No c/o reduced urine output, pedal edema , facial puffiness.

PAST HISTORY:

N/k/c/o DM , BA, EPILEPSY.

PERSONAL HISTORY:

HABITS: OCCASIONAL TOBACCO USE

He follows a mixed diet. 

Appetite -Normal,

Bladder movements- normal 

Bowel movements- Normal . 

Sleep- Adequate.

FAMILY HISTORY: No significant family history.

GENERAL EXAMINATION : 

patient is conscious ,coherrent, co operative and well oriented to surroundings. He is moderately built and nourished. 

Mild Pallor ,no cyanosis, no icterus, no lymphadenopathy. 

Vitals:

Temperature: 99.8

Pulse rate: 112 beats / min.

 Respiratory rate: 36 cycles / min.

 Bp: 220/140 mmhg

Spo2: 94@RA

Grbs: 104mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.

RS: BAE+, B/L crepts +

P/A: Soft, Non-tender

CNS: NAD

INVESTIGATIONS:

(8/4/22)

RBS-90MG/DL

HB-9.8

TLC-11,500 (87%N)

PLT-2.67

DIAGNOSIS: 

CRF ( CHRONIC TID)

H/O LRTI ( 10DAYS BACK) - ? FUNGAL PNEUMONIA

HFrEF (EF-42%) WITH CARDIOGENIC PULMONARY EDEMA, HTN + (? RESIDUAL PNEUMONIA)

TREATMENT:

1) INJECTION LASIX 40 MG IV TID TAB.

2)TAB. PAN 40MG PO/OD 

3)TAB. ZOFER 4 MG PO/BD 

4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD

6)SYRUP GRILLINCTUS 10 ML PO/TID

7)TAB.MONTEK -LC PO /BD

8)INJ. EPO 4000IU S.C WEEKLY ONCE

9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 

10) T.NICARDIA 20MG PO BD

11) T.ARKAMINE 0.1MG PO BD

12)TAB.CARDIVAS 3.125MG PO /BD

13)TAB.ECOSPRIN-AV 75/20MG PO/HS

14)I/O CHARTING,TEMP CHARTING

15)TAB.DOLO 650 MG PO/SOS (IF FEVER )

16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101