46 year female with C/O Shortness of breath

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Unit 2 admission 

Date: 26/01/2021  

Patient complained of shortness of breath (today evening 6.00pm). From today morning, patient was on fasting, @4.00 pm she took one glass of toddy

At 6.00pm after having meals with chicken, she started walking to her relative house, suddenly she had shortness of breadth(grade 4) associated with sweating.

No H/O fever, vomitings, loose stools, pedal edema, chest pain, palpitations, orthopnea, PND. 

Not a K/C/O DM2, HTN, asthma, TB, epilepsy, CAD. Patient had similar episode of SOB during exertion 2 months back and got relieved with (? medication)

VITALS:

Bp: 150/100mm Hg

PR: 91/min

RR: 28 per minute

SpO2 at room air: 99%

Grbs: 239 mg/dl

Systemic examination:

CVS: S1 S2 heard

RS: 

BAE present, normal vesicular breath sounds heard

Right infra axillary crepitus present 

Per Abdomen: Soft, non tender 

CNS:

 no focal deficits

Provisional diagnosis:

SOB under evaluation