General medicine case -6

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A 55 year old male who is daily wage worker  by occupation came to the OPD complaining about 

- Shortness of breath ,pedal edema since 3 months 

- cough since 2 months

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

He used to get up at 5:00 am in the morning, used to have tea and  the time until afternoon talking to his friends then used to have lunch at 1 PM which is rice.He used to return home by 6 in the evening then he used to freshen up and drink alcohol (150-200ml per day) and used to have dinner at 9 PM and sleep after that.

The Patient was apparently asymptomatic 3 months back then he developed bilateral pedal edema  which was pitting type , insidious in onset along with swelling of hands and facial puffiness.He also developed sob which was insidious onset , aggravated on doing his work .He also complained of back pain 

He also complained of cough since 2 months which was productive .

PAST  HISTORY:-

He was chronic alcoholic and smoker since 30 years and stopped alcohol and smoking 2months back .

No history of diabetes Mellitus , hypertension, tuberculosis,asthama .

He had a history of traumatic injury to his right eye while cutting granite stone 

The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma, hypertension

Personal history : 

- The patient has no loss of appetite

- He takes mixed diet

- No sleep disturbances

- He consumes 90 ml of alcohol daily, was a cigarette smoker 3 months back where he used to take 1pack per day

Family history :

- There are no similar complaints in the family members

Treatment history :

- He is not a known case of drug allergy.

General examination :

Patient is conscious,coherent , cooperative well oriented to time.

Pallor is present (Hb-8.9  /dl)

Icterus -present 

No cyanosis

No clubbing of fingers and to

- No lymphadenopathy

- No pedal edema

Vitals :-

Temperature-afebrile

Respiratory rate-20 cycles /min

Pulse  rate-72bpm 

Blood pressure-140/70mmHg

Spo2-99%at room air 

Systemic examination : 

CVS-

Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- bowel and bladder sounds heard

- no palpable mass 

- patient has mild amount of fluid 

CNS:-

- Patient is conscious

- Speech is present

- Reflexes are norm

Investigations:-

Clinical images:-

TAB. NICARDIA 20 mg BD 

2. TAB. NODOSIS 500 mg BD

3. TAB. OROFER XT PO BD 

4. INJ. ERYTHROPOIETIN 4000IU WEEKLY ONCE 

5. TAB. SHELCAL PO OD

6. INJ. THIAMINE 100 mg in 50 ml NS IV/TID 

7. Fluid and Salt restriction