Final practical examination(long case)

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Date of admission: 3/02/2022.

A 67 old male patient came to the OPD with the chief complaint of shortness of breath and bilateral pedal edema ,pitting type since 3 days, orthopnea, paroxysmal nocturnal dyspnea.

History of present illness:

Patient was apparently asymptomatic since 20 yrs back then he developed sever cough with sputum went to hospital and diagnosed with TB use ATT course for 9 months and relieved.

Patient developed shortness of breath of grade 2-3, grade 2 pedal edema of pitting type.

History of past illness: know case of TB. Not a know case of diabetes, hypertension, asthma, epilepsy.

Patients daily routine:

Patient wakes up at 4am and he goes to work( tea stall) , around 11 O clock he returns his home and he will take bath and haves his meals at 12 O clock ( he skips his breakfast), and he take a nap, around 3 O clock again he goes to his work and returns his home at 10 O clock , dinner at 10pm and goes to bed.

Personal history:

Diet: mixed.

Appetite: decreased since 1yr.

Sleep : decreased

Bowel and bladder movements are normal.

Chronic alcoholic since 50yrs (3times a week 180-360 ml).

Chronic smoker since 50 yrs (18 beedis/day).

Drug history: not allergic to any of the known drugs 

Family history: no relevant family history.

General examination: clubbing is seen.

Vitals: 

Temperature: afebrile ,Pulse rate: 98 beats per minute, BP: 110/80 mm Hg, Respiratory rate: 26 cycles per minute, SPO2:83, GRBS :111mg/dl.

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 coherent.

Abdomen: distended.

Clubbing:

Investigations:

Provisional diagnosis:cor pulmonale, copd, with history of TB.

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.