General medicine final practical short case

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs

A 67 yr old male patient presented to the opd with the chief complaints of shortness of breath since 2-3 days, bilateral pedal edema since 3 days, orthopnea,PND

History of present illness: patient was apparently normal 20 yrs Back then he developed severe cough with sputum and also shortness of breath.then he was diagnosed with TB.he used ATT course for 9 months and relieved. Now patient again developed shortness of breath of grade 2-3, pedal edema of pitting type.

Past history: known case of TB. Not a known case of diabetes, hypertension, asthama , epilepsy.

Personal history: patient follows a mixed diet.patient complaints of decreased appattite since 1 yr.normal bowel and bladder movements. Patient is a chronic alcoholic since 50 yrs(180-360ml) three times a week.he also have a habbit of smoking since 50 yrs (18beedis per day) .

Family history : no relevent family history

Drug history : not allergic to any of the known drugs.

On examination patient is conscious coherent cooperative. 

Clubbing present.

No cyanosis, no icterus, no pallor .

Vitals:

pulse rate: 98BPM

 temperature: afebrile

BP: 110/80

respiratory rate: 26 cycles per min

 spo2: 83

GRBS:111mg/dl

Systemic examination: 

Cvs: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs. s1 and s2 heard

Respiratory system: bilateral air entery present , wheeze present, Position of trachea- central, 

CNS: patient is concious .reflexs are normal

Abdomen: distended

Investigations to be done: x- ray, echocardiogram.

Provisional diagnosis: cor pulmonale, with history of TB 20 yrs back.

Differential diagnosis: pulmonary hypertension

Treatment plan: 

INJ.LASIX 40 mg IV/BD

FLUID RESTRICTION <1.5L/DAY, SALT RESTRICTION <2 G/ DAY

NEB WITH DUOLIN,BUDECORT 6TH HRLY

INJ.AUGUMENTIN 1.2gm/IV/BD

INJ.PAN 40 mg IV/OD

INJ THIAMINE 1 AMP IN 100MLNS/IV/TID

BP/PR/RR/TEMP CHARTING 4TH HRLY