Dr Bhavya
75 year old male with SOB.
75 year old male resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days.
History of presenting illness.
Patient was apparently asymptomatic 2 years ago ,later he developed SOB,pedal edema and generalised weakness for 2 weeks and for which he was treated.
2 months ago he developed cough with sputum , which is white in color, not blood stained and non foul smelling. And also SOB which gradually progressed from Grade 3 to Grade 4 ,one month ago.
He also developed facial puffiness 20 days back . Along with pedal edema with is of pitting type.He has chest pain since 10 days which aggrevated with SOB.
No H/O fever with rash,hemoptysis,nausea,vomiting,constipation.
Past history:
Not a k/c/o HTN,DM,Thyroid,asthma,epilepsy,Congenital heart Disease.
Personal history:
Diet-mixed
Appetite-normal
Bowel and bladder movements-Regular
Sleep -adequate
Addictions-chronic smoker since 30 yrs (4 per day)
Occasionally alcohol
GENERAL EXAMINATION :
Patient is conscious , coherent and cooperative and well oriented to time place
and person,
Thin built and moderately nourished
Pallor- present
B/L pitting type of Pedal edema present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Weight loss of 4kgs within 1 day after diuretics.
VITALS :
Temperature- 98.6 F
Pulse rate- 92 bpm(Irregularly regular)
Respiratory rate-14cpm
BP- 110/80 mm Hg
Spo2- 112%
GRBS-130 mg%
Systemic Examination:
Respiratory system.
Inspection-
Shape of chest-elliptical and symmetrical
Position of trachea-midline.
Bilateral symmetrical chest movements on respiration.
Palpation-
No local rise of temperature and no tenderness.
Apexbeat
TVF
Percussion-
Ascultation-
crepts heard over right infra mammary and infra axillary regions.
Investigations:
ECG
T wave absent, narrowed QRS complex
2dEcho
Chest x ray
