General Medicine Prefinal Exam Case
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Date of Admission : 19-12-2021
A 48-YEAR-OLD MAN WITH GRADE IV SOB.
A 48 year-old man came to the hospital with chief complaints of pedal edema since 1 month,shortness of breath which aggravated since 2 hours,productive cough since 2-3 days.
History of present illness :
The patient was apparently asymptomatic 1 month ago when he noticed swelling in both his legs which was gradually progressive, extending to his knees.
History of increased shortness of breath since 1 day which aggravated to Grade 4 SOB since 2 hours, associated with orthopnea and PND.
H/o Productive cough since 2-3 days.
No H/o decreased urine output.
No H/o facial puffiness.
No h/o fever, cold.
Patient is a driver . The patient's daily routine was to wake up around 5'O clock in the morning and starts working early to his shifts . He will have breakfast around 8 to 9 am. He takes rest according to his shift timings . He used to have dinner around 8 to 9 pm and sleep for 5 to 6 hours .
Past history :
The patient is not a known case of Hypertension ,TB, Bronchial Asthma,Epilepsy, CVD.
Personal history :
Diet- mixed,
Appetite and Sleep - Decreased,
Bowel movements - Regular.
He smokes 3-4 cigarettes a day since the past 10 years.
He consumes alcohol once or twice a week.
Family history :
Patient's father is a known case of diabetes and hypertension.
Treatment History:
Patient has no history of medications
No drug allergy
General examination:
Patient is conscious, coherent, cooperative.
Bilateral, pitting type of pedal edema present.
No signs of Pallor,
No icterus,
No clubbing,
No cyanosis ,
No lymphadenopathy.
Vitals:
Temperature:97.3 F
Bp: 170/120 mm Hg
Pulse rate:126 bpm
Respiratory rate : 34 cpm
Grbs: 206 mg/dl
SpO2 at room air : 83%
Systematic examination:
CVS:
S1 and S2 heard
Respiratory System:
BAE +,
ISA and IAA inspiratory crepts +,
B/L ISA Wheeze +
Position of trachea :Central
ABDOMEN :
Abdomen -soft
No tenderness observed
Central Nervous System:
Patient is conscious
Speech is normal
Reflexes are normal
CLINICAL IMAGES :
Heart failure ?
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