CBBLE UDHC SIMILAR CASES
UNIT 3 AND 6 ADMISSION
AMC BED NO. 2
67Y/MALE
PATIENT CAME WITH C/O SOB GRADE II TO III SINCE 1WEEK, PEDAL EDEMA GRADE - II PITTING TYPE SINCE 2 DAYS, ORTHOPNEA +, PND +.
HOPI : PT WAS APPARENTLY ASYMPTOMATIC 20 YEARS BACK THEN PATIENT DEVELOPED SEVERE COUGH WITH SPUTUM WENT TO HOSPITAL AND DIAGNOSED WITH TB USED ATT COURSE FOR 9MONTHS AND RELIEVED.
PATIENT DEVELOPED SOB SINCE 1 WEEK
SOB : GRADE - I INITIALLY PROGRESSED TO GRADE - II & III, ORTHOPNEA +, PND +
PATIENT DEVELOPED PEDAL EDEMA 2 DAYS BACK AND ALSO C/O MILD FACIAL PUFFINESS
PEDAL EDEMA - GRADE II , PITTING TYPE
NO C/O PALPITATIONS, GIDDINESS, FEVER, COLD, COUGH, BURNING MICTURITION.
PAST HISTORY : NO SIMILAR COMPLAINTS IN THE PAST
N/K/C/O HTN, DM, EPILEPSY, ASTHMA, CAD
PERSONAL HISTORY : APPETITE - DECREASED
BOWEL MOVEMENTS - REGULAR
CHRONIC ALCOHOLIC SINCE 50 YEARS 3 TIMES A WEEK ( 180-360 ML / DAY)
CHRONIC SMOKER SINCE 50 YEARS - 18 BEEDI / DAY.
O/E : PATIENT IS C/C/C
PALLOR -
ICTERUS -
CYANOSIS -
EDEMA OF FEET +
LYMPHADENOPATHY -
CLUBBING + ( GRADE 3 )
VITALS :
TEMP : AFEBRILE
PR : 98 BPM
BP : 110/ 80 MM OF HG
RR : 26
SPO2 : 83 ON RA
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD, NO MURMURS HEARD
RESPIRATORY SYSTEM :
BILATERAL AIR ENTRY PRESENT, ON ASCULTATION WHEEZE PRESENT, INSPIRATORY CREPTS NOTED IN IAA, ISA
CNS : NAD
PA : ABDOMEN DISTENSION +
FAMILY HISTORY: NOT SIGNIFICANT
INVESTIGATIONS:
