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1. CASE ON CAD,BA,HTN
17-04-2014

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