1802102020- SHORT CASE
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A 67 year old male patient came to OPD with chief complaints of shortness of breath and bilateral pedal edema since 3 days,paroxysmal nocturnal dyspnea, orthopnea.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 20 years back and then he noticed severe cough with sputum then he went to the hospital and diagnosed as TB use ATT course for 9 months and relieved.
Patient has shortness of breath which is of grade 2-3.
Pedal edema is of pitting type.
PAST HISTORY:
Patient was a known case of tuberculosis.
No history of diabetes, hypertension, CAD, asthma, epilepsy, thyroid disorders.
No history of any surgeries in the past.
No history of similar complaints in the past.
PERSONAL HISTORY:
Appetite: decreased since 1 year
Diet: mixed
Sleep: inadequate
Bowel and bladder movements: regular
Micturition: normal
Addictions:
Chronic smoker since 50 years ( 18 beedis/ day)
Chronic alcoholic since 50 years( 3 times a week 180- 360 ml)
FAMILY HISTORY:
No member of the family had similar complaints.
TREATMENT HISTORY:
Patient had not undergone any treatment prior.
He is not allegic to any known drugs.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Clubbing - present
There is no signs of pallor, icterus, cyanosis and generalised lymphadenopathy.
VITALS:
Temperature: afebrile
Blood pressure: 110/ 80 mm Hg
Pulse rate: 98 beats / min
Respiratory rate: 26 / min
Spo2 : 83 % at room temperature
SYSTEMIC EXAMINATION :
CVS:
No thrills
No cardiac murmurs
S1 and S2 heard
RESPIRATORY SYSTEM:
Bilateral air entry- present
Wheeze- present
Position of trachea- central
CNS:
Patient is conscious
ABDOMEN: distended
PROVISIONAL DIAGNOSIS:
Cor pulmonale , COPD, with history of tuberculosis 20 years back.
TREATMENT:
1. Fluid restriction <1.5L/ day
2. Salt restriction <2 g/day
3. Neb with DUOLIN , BUDECORT 6th hrly
4. Inj. PAN 40 mg IV/OD
5. Inj. AUGUMENTIN 1.2 gm /IV/BD
6. Inj. THIAMINE 1amp in 100 ml NS/IV/TID
7. Monitor vitals 4 th hourly
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