1802102088 short case

 February 9, 2022

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A 67 yrs old male patient presented to the opd with chief complaint of shortness of breath , bilateral pedal edema since 3 days , paroxysmal nocturnal dyspnea, orthopnea

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 years back then developed severe cough with sputum. Patient visited nearby hospital and was diagnosed as tuberculosis and use ATT course for 9 months and it was relieved

Patient has shortness of breath which is of grade 2-3

Pedal edema of pitting type

PAST HISTORY:

Patient is a known case of tuberculosis

No history of diabetes, hypertension, asthma and epilepsy

No history of any surgeries in the past

PERSONAL HISTORY:

Diet- mixed

Appetite- decreased

Sleep- inadequate

Bowel and bladder movement- regular

Addictions:

Chronic smoking since 50 years ( 18 beedis/day)

Chronic alcoholic since 50 years( 3 times a week 180- 360ml

FAMILY HISTORY:

No significant family history

TREATMENT HISTORY:

Patient is not allergic to any known drugs

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative

No icterus , no anemia ,no lymphadenopathy

VITALS:

Temperature- afebrile

BP- 110/80mm of Hg

Pulse rate- 98 beats/min

Respiratory rate- 26 breaths/min

SYSTEMIC EXAMINATION:

CVS:

No thrills

No cardiac murmurs

S1S2 heard

RESPIRATORY SYSTEM:

Bilateral air entry is present

Wheeze is present 

Position of trachea- central

CNS:

Patient is.conscious

ABDOMEN-

Distended

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Cor pulmonale, with history of tuberculosis 20 years back

TREATMENT:

Fluid restriction<1.5 L/day

Salt restriction <2g/day

Neb with Duolin , budecort 6 th hourly

Inj pan 40mg IV/OD

Inj Augumentin 1.2gm/IV/BD

Inj Thiamine 1 amp in 100ml/NS/IV/TID

Monitor vitals 4 th hourly