A 64 year old with C/o breathlessness

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I've 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 a diagnosis and treatment plan.

Patient cam to casuality with c/obreathless ness from 1 hour.

Patient was.apparently asymptomatic 1 hr back then he developed breathlessness since 1 hrs which was sudden in onset, MMRC GRADE IV,aggrevated on exertion and not associated with wheeze.

H/o cough since 3 months, occasional, associated with sputum and used local medication.

No c/o chest pain,chest tightness,hemptysis. 

K/C/O- DM , SINCE 3 MONTHS

K/C/O-HTN SINCE 3 MONTHS

N/K/C/O-TB ,EPILEPSY,ASTHMA,CAD.

PERSONAL HISTORY-

SLEEP-AADEQUATE 

APETTITE-NORMAL 

BOWEL AND BLADDER MOVEMNTS-REGULAR 

CIGARETTE SMOKING 1 PACK PER DAY SINCE 40 YRS

ALCOHOL-WHISKEYoccasionally

O/E-

Patient on mechanical ventilation 

Mode-SIMV-VC

Fio2-40

PEEP-05

E4VTM6

Bp-110/70 mmhg

PR-118bpm

RR-47cpm

TEMP-101.4F

CVS-S1 S2 HEARD, no murmurs

RS-BAE PRESENT ,

B/L BASAL CREPTS PRESENT

P/A- soft and non tender.

PROVISIONAL DIAGNOSIS-ACUTE CORONARY SYNDROME WITH TYPE II RESPIRATORY FAILURE WITH MECHANICAL VENTILATION  WITH DM WITH HTN

TREATMENT-

1.RYLES FEED

2.INJ.CEFTRIAXONE 1GMIV/BD

3.INJ HEPARIN 5000 IV/TID

4.INJ DOPAMINE 2.5MG IV Infusion

5.INJ. DOBUTAMINE 1 MP IN 45 ML NS@10 ML/HR TO MAINTAIN MAP>65 MMHG

6.TAB.ATORVASTATIN 40 MG RT /OD

7.TAB.ASPIRIN 75 MGRT/OD

8.INJ.LASIX 20 mg IV/BD

9.Tab.CLOPIDOGREL 75 MG RT/OD

10. TAB.IVABRADINE 7.5 MG RT/BD

11.TAB DAPAGLIFLOZIN 10 MG RT/OD

12.MONITOR VITALS INFORM SOS