63 MALE WITH SEPTIC SHOCK, CARDIOGENIC SHOCK, PERSISTENT AF WITH FVR, HFMEF NCNC ANAEMIA 2ry TO BLOOD LOSS, UTI, B/L PLEURAL EFFUSION, GRADE-4 BEDSORE, S/P D11-D12 LAMINECTOMY WITH PARAPERASIS

PRESENTING COMPLAINTS : 
PATIENT CAME WITH C/O.DIFFICULTY IN SWALLOWING AND SHORTNESS OF BREATH SINCE TODAY MORNING 

HISTORY OF PRESENTING COMPLAINTS :
PATIENT WAS APPARENTLY NORMAL YESTERDAY, SUDDENLY HAD DIFFICULTY IN SWALLOWING ASSOCIATED WITH DROOLING OF SALIVA AND DIFFICULTY IN SPEECH.
SHORTNESS OF BREATH SINCE MORNING SUDDEN IN ONSET GRADUALLY PROGESSIVE FROM GRADE-3 TO GRADE-4.
H/O.FALL AT HOME 20 DAYS BACK AT HOME FOLLOWED BY WEAKNESS OF BOTH LOWER LIMBS AND LAMINECTOMY DONE AT OUT SIDE HOSPITAL, THEY DIAGNOSED D11 WEDGE COMPRESSION FRACTURE, FRACTURE MULTIPLE RIBS WITH HEMOTHORAX WITH ATRIAL FIBRILLATION.

PAST HISTORY:
NO H/O. HYPERTENSION 
NO H/O. DIABETES MELLITUS 
NO H/O. CAD /CVA 
NO H/O. TB/ ASTHMA / EPILEPSY 

TREATMENT HISTORY:
NO PREVIOUS HISTORY OF MEDICATIONS 

PERSONAL HISTORY: 
Diet - mixed 
Appetite - normal 
Bladder and Bowel - constipation
Sleep - adequate 
Alcohol - Regular 90ml/day since 20yrs
Smokes 1pack/day since 25 yrs 
No drug addictions 

FAMILY HISTORY:
No H/O HTN/DM/TB/ASTHMA/EPILEPSY/CAD/THYROID DISORDERS in the family.

PROVISIONAL DIAGNOSIS :
ACUTE CVA WITH DYSPHAGIA, PERSISTENT AF WITH FVR, S/P D11-D12 LAMINECTOMY, GRADE-4:BEDSORE.

GENERAL PHYSICAL EXAMINATION:
HEIGHT - 164 cms
WEIGHT - 60 kg
NO PALLOR 
NO ICTERUS 
NO CYNOSIS 
NO CLUBBING 
NO LYMPH EDNOPATHY 

DAY 1 ON EXAMINATION: 01/04/2025 at 4.30 PM
TEMP - 98. 3 f
PULSE - 114/min irregularly irregular.
HR - 148/min irregular heartbeat 
APEX PULSE DEFICIT - 20
BP - 100/70 mm of hg
RR - 30 / min
SPO2 - 100% on 6 LTS. O2
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , LEFT SIDED CREPTS PRESENT IN MA,ISA , AA
PA - SOFT , NON TENDER 
CNS - NFND 

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