35 year male with shortness of breath.

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Complaints: 

1) Shortness of breath ( grade 3-4 ) since 20days.

2) Palpitations since 20days .

3) Cough with expectoration since 5-6 days 

4) Pedal edema since 3-4 days 

HOPI : 

A 35 year male patient resident of sathupalli ( village in khammam) , worker in barshop had history of alcohol intake since 15 years.Patient usually takes alcohol around 360ml/day.Patient had increased alcohol intake since 1 month along with decreased food intake, stopped going to his duty and had shortness of breath since 20 days along with palpitations and visited local doctor , said that he was anemic and has increased HR and he was prescribed some medication and but the SOB didn't reduced and cough with expectoration was started last 5-6days followed by pedal edema and was referred to the higher centres for further evaluation.

Past history: 

No history of similar complaints in the past.

Known alcoholic ( 360ml/ day) 

Occasional smoker.( According to attenders)

Personal history :

Appetite : decreased 

Diet : mixed 

Sleep : inadequate 

Bladder : normal

Bowel movements: regular 

Addictions : alcoholic and smoker 

 

Family history:

No significant family history 

General examination:

Pallor: absent

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

Treatment: 

1) Inj Amiodarone 150mg /IV/STAT.

2) inj Amiodarone 900mg in 32 ml NS@ 1mg/min for 6hrs 

3) Inj Amiodarone 900mg in 32 mlNS @ 0.5mg/min for 18 hrs 

4) Inj Augmentin 1.2g/IV/BD

5) inj Lasix 40mg/IV/OD

6) Tab Azithromycin 500mg/PO/OD

7) Inj Thiamine 200mg /IV /TID.

8) Inj Hydrocort 100mg/IV/BD.

9) Neb Duolin and budecort 8th hrly.