Long case ( FINAL PRACTICAL)
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A 67year old male , daily wage worker has come to casualty with chief complaints of acute onset of shortness of breath since 1 week
Patients also complaint of inability to breath during sleeping , but there decrease in the SOB on sitting position since one week.
Patient also complaints of swelling in the foot since one day .
Patient also complaints of cough with expectoration.
HISTORY OF PRESENT ILLNESS:
Patient was apparently well , asymptomatic before illness and noted sudden onset of shortness of breath since a week and wheeze . He also complaints of orthopnea and paroxysmal nocturnal dyspnoea since one week.
Patient also complaints of cough with expectoration but not heamoptysis. There is increase in cough frequency during early morning after waking up.
Patient also has pedal oedema which is pitting type.
No history of fever , chest pain, chest tightness .
It is known case of sweating and palpation .
PAST HISTORY:
Known case of tuberculosis , 20years back and used ATT for it.
No history of similar complaints in the past.
No history of diabetes, asthma , epilepsy, hypertension.
No history of blood transfusion or any surgery in the past .
Patients daily routine:
Patient wakes up around 4 in the morning and he goes to work , around 11 O clock he returns his home and he will take bath and haves his meals at 12 O clock without any breakfast in the morning, and he take a nap, around 3 O clock again he goes to his work and returns his home and have dinner at 10pm and goes to bed.
PERSONAL HISTORY:
Diet : mixed.
Appitite : decreased.
Bowel - bladder movement : normal.
Sleep: inadequate.
Addictions : patient consumes alcohol since 18 years , about 3 to 4times in a week , around 180-360 ml / day.
Patient also has a habit of smoking bedi since 18 years and takes one packet per 2 days .
FAMILY HISTORY:
No similar complaints are found in the family.
TREATMENT HISTORY:
Patient is not allergic to any known drugs.
GENERAL PHYSICAL EXAMINATION:
Patient was coherent , cooperative, concious and well oriented to the place .
Known case of pedal oedema and clubbing
No pallor, cyanosis , icterus and generalised lymphadenopathy.
VITALS:
Temperature : afebrile.
Pulse rate :80 beats/ min.
Respiratory rate : 20 cycles/min.
Blood pressure: 110/70 mm Hg.
SYSTEMIC EXAMINATION:
CVS: S1 and S2 heard ,bilaterally symmetrical chest wall, no thrills and murmurs heard.
Respiratory system: bilateral air entry present, wheezing present, position of trachea central.
CNS:Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
Abdomen : appear to be distented.
INVESTIGATION:
LIVER FUNCTION TESTS:
Serum creatinine
Serum electrolytes:
HEMOGRAM:
Chest X ray:
ECG :
PROVISIONAL DIAGNOSIS:
Cor pulmonale , COPD with a history of Tuberculosis.
TREATMENT:
Inj. Lasix 40 mg IV /BD.
Fluid restriction <1.5L/ day
Salt restriction:<2g/ day.
NEB : duolin, budecort 6th hourly.
Inj. Augmentin 1.2 gm/IV/BD.
Inj. Pan 40mg IV/OD.
Inj. Thiamine 1 amp in 100ml NS /IV/TID.
BP/PR/RR/TEMP charting 4th hourly.
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