60 year old male with trunkal obesity with URTI, HFMEF, DM, HTN

A 60 year old male came to casuality with

C/o Cough, cold since 3 days

        Chest pain since 1 day

        Fever since 1 day

HOPI

Patient was apparently asymptomatic 3 days ago then he developed cough with sputum, scanty in quantity, green in color associated with cold and nasal blockage

H/o Fever, low grade, continuous non aggravating and no relieving factors

No h/o rash, retroorbital pain, arthralgia

C/o chest pain, diffuse, squeezing type associated and aggrevating with cough, non relieving 

No h/o abdominal pain, vomiting, diarrhea 

No h/o seizures, tremors

Past history :

K/c/o DM, HTN since 10 years and on unkown medication 

N/k/c/o Asthma, CAD, CVA, Thyroid disorders, Epilepsy

General examination 

Pt is C/C/C

No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema

Vitals

Temperature - 100.8°F

PR - 104 bpm

BP - 110/70 mmHg

RR - 22 cpm

SpO2 - 93 @ 4L O2

GRBS - 301 mg%

Systemic Examination

CVS - S1,S2 heard

RS - BAE present 

CNS - NFND

P/A - Soft, Non tender




Investigations on admission (06/01/2024)

Serology - Negative
BGT - AB positive
Hb - 8.9
TC - 11,000
Platelets - 3.5
Smear - Normocytic normochromic Anemia

CUE
Albumin - +++
Sugar - +
Pus cells - 2-4
Epithelial cells - 2-3

RFT
Urea - 42
Creatinine 1.5
Uric acid 6.0
Sodium 137
Potassium 3.9
Phosphorus 2.0
Chloride 103
Calcium 9.3

LFT
TB - 0.94
DB - 0.19
AST - 22
ALT - 20
ALP - 213
TP - 6.3
Albumin - 3.3
A/G - 1.09

HbA1c - 6.9

Trop I - 39.5



Provisional Diagnosis

URTI

ANGINA with RBBB

HFMEF with MIDRANGE EJECTION FRACTION


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