63yr old male complaints of fever,cough since 1 month difficulty in breathing since 2 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

A 63yr old male patient came with the complaints of fever,cough since 1 months and difficulty in breathing since 2 days

HOPI 

Patient was apparently asymptomatic 1 month back and then developed fever intermittent low grade relieved on taking medication associated with chills and rigor 

C/o cough since one month associated with sputum sometimes 

C/o difficulty in breathing since 2 days

Past history

K/C/O CAD Post PTCA status 8 yrs back 

K/C/O HTN since 3 months but not on any medication 

H/o blood transfusion 8 days back - 1 PRBC ,

N/K/C/O DM , CVA , Asthma , TB, Epilepsy

Personal history

Diet : mixed 

Appetite: normal 

Sleep : adequate 

Bowel and bladder : regular 

Addictions: 

Alcohol - used to consume alcohol stopped 15 yrs back 

H/o smoking + but stopped 15 yrs back 

General examination: 

Patient is c/c/c well oriented to time place person

He is ill built and nourished 

Vitals : 

Temperature - 101 F @4pm 

                           100 F @5pm 

                           98.7 @6pm 

BP- at 4:15pm 110/60mmHg 

 5:45pm 70/30mm hg 

6pm 80/40mmhg(noradrenaline 4ml/hr ) 

6:45pm 70/40mmhg (ND - 6ml/hr) 

7:30pm 70/50mmhg (ND - 8ml/hr) 

8pm 120/80mmhg (ND - 8ml/hr) 

9pm 120/80mmhg(ND- 7ml/hr) 

PR - 96bpm 

RR - 16cpm 

CVS - S1 S2 heard no murmurs

RS - BAE PRESENT NVBS HEARD

P/A -Soft , non tender 

CNS -NFND 

Investigations: 

Hemogram (20/10/23) 

RFT (20/10/23)

Hemogram (21/10/23) 

2D echo : 

Provisional diagnosis: 

PYREXIA UNDER EVALUATION , HEART FAILURE (EF - 54%) SECONDARY TO CAD - S/P PTCA 8yrs back 

Treatment: 

IV fluids : UO + 30ml/hr 

Inj.NORADRENALINE (6ml/hr IV infusion ) increase /decrease according to BP - 0.16mg = 1 ml 

Tab. ROVASTATIN + CLOPIDOGREL PO/HS (75MG + 10 MG )