60 yr old male with lower back ache and shortness of breath












 A 60 yr old male resident of daily wage labourer  by occupation came with chief complaints of lower back ache since 10 days and shortness of breath since 5 days 

HISTORY OF PRESENTING ILLNESS 

Pt was apparently asymptomatic 6 months back the he developed sudden onset of chest pain with high blood pressure and was diagnosed with MI and PTCA was done .

Now since 5 days she developed sudden onset of chest pain and shortness of breath

Chest pain is retrosternal,non radiating

Shortness of breath since 5 days grade ll to grade lll ,

PAST HISTORY

K/c/o DM since 10 years 

PERSONAL HISTORY

Diet  mixed

Appetite Normal

Sleep  adequate

Bowel and bladder Regular

Addictions alcoholic since 20 yrs 70ml/day and smoker since 20 yrs 2 chutta/day 

GENERAL EXAMINATION

Patient is conscious coherent and cooperative

Moderately built and nourished

No pallor, Icterus, cyanosis, generalized lymphadenopathy,edema 

Mild clubbing is present

Vitals 

Temp Afebrile

Bp 130/70 mm Hg 

PR 82 bpm 

RR 18 cpm 

GRBS 106 mg/dl 

Systemic Examination

CVS S1 S2 Heard no murmurs

RS BAE + NVBS heard

P/A soft and non tender

CNS No focal neurological deficit

INVESTIGATIONS

DIAGNOSIS

Lower back ache under evaluation 

Treatment

Tab.GLIMI-M PO/OD

Tab.ECOSPRIN 150 mg+ Tab.ATORVASTATIN 40 mg PO/HS

Tab.PAN 40 mg PO/OD

Tab.ULTRACET 1/2 tab/QID













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