A case study in cad
- 2. A 59years old male patient was admitted in the hospital on 26/1/2011 . C/O: fever with chills and rigors since 3 days , breathlessness since last evening , cough with expectoration , generalized body pains , abdominal discomfort . O/E: patient: conscious / oriented , pallor: nil , cyanosis: nil , clubbing: nil , edema: nil , B.P:210/140mmHg , P/A: soft , no organomegaly is seen , CVS: S1S2+ , RS:NBAE , CNS: NAD .
- 3. PAST MEDICAL HISTORY: known case of DM , systemic HTN, since 15 years and also a known case of lateral wall ischemia (CAD) and bronchial asthma since 4-5 years . SHTN , BA , CAD are under medication . SOCIAL HISTORY: non – alcoholic , non – smoker .
- 4. LAB INVESTIGATION: W.B.C Count 9.16 4.0 – 11.0*10*3/ml differential count Neutrophils *80% 40 – 75% lymphocytes *19% 20 - 40% monocytes *0.1% 2 - 10% (1hr) *122 5 - 20mm F.B.G 71 60 - 110mg/dl blood urea *64 10 – 50mg/dl serum creatinine 0.7 0.5 – 1.2mg/dl electrolytes: sodium 136 136 - 145mmol/lit potassium 4.2 3.5 – 5.1mmol/lit chloride 104 95 - 111mmol/lit carbonate 23 21 - 20mmol/lit P.P.B.G *272 70 - 125mg/dl urine 24hrs – protein 125 24 - 140mg/day
- 5. SPUTUM: GRAM’S STAIN: >25 polymorphs , <10epithilial cells/10*field . few gram (+)ve cocci in pairs and chains . reduced normal flora . REPORT: normal flora grown in culture . PRELIMINARY BLOOD TEST: no growth in culture after 48hrs incubation .
- 6. URINE: colour : straw yellow , appearance: slightly turbid , reaction PH: 6.0 , sugar: 2+ (R) , albumin: trace (R) . GRAM’S STAIN: occasional pus cells , no organisms seen . DEPOSITS: pus cells: 8 – 10 cells/HPF epithelial cells: 2 – 3 cells/HPF R.B.C: occasional cell/HPF , cast cells: nil , crystals: nil , urine for ketone: negative .
- 7. DIAGNOSIS: TYPE 2 D.M , systemic HTN , CAD , BA .
- 8. S.NO DRUGS DOSE ROUTE FREQU ENCY FRO M 2/2 TO 27/1 1) INJ. cefizone 2mg IV OD YES YES 2) TAB. azithromycin 500mg P/O OD YES YES 3) TAB. pantocid 40mg P/O OD YES YES 4) TAB. Ganaton 150mg P/O BD YES YES 5) TAB. Bidanzen forte 10mg P/O OD YES YES 6) TAB. renerve plus 1tab P/O TDS YES YES 7) SYP. Mucolyte 120ml P/O Q6H YES YES 8) NEB. Duolin 1resp P/N Q8H YES YES 9) NEB. Budecort 1resp P/N BD YES YES 10) NEB. Mucolyte 1amp P/N TDS YES YES
- 9. OWN MEDICATIONS: S.NO DRUGS DOSE ROUTE FREQUENCY 1) TAB. ANGIZEN.CD 180mg P/O OD 2) TAB. ATORVA 20mg P/O HS 3) TAB. TELMA 80mg P/O OD 4) TAB. CABLIACTONE 1tab P/O OD 5) TAB. NATRILIX 1.5mg P/O HS 6) INJ. HUMAN MIXTARD S/C 1 – 0 - 1