General medicine long case history
July 31st 2022
Final practical examination (long case)
July 31st 2022
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A 67 year old man who is daily wage worker by occupation presented our opd with the cheif complaint of shortness of breath since 1 week
Swelling in the legs since 4days
Cough associated with expectoration since 4days
History of present illness :
Patient was apparently asymptomtic 1week back
Then he suddenly developed shortness of breath and wheeze
He also complains of cough associated with expectoration
He also complains of orthopnea and nocturnal dypnea
He has sweating and palpations
He also has pitting edema
No h/o of fever,chest pain
Patients daily routine:
Patient wakes up around 4 in the morning and he goes to work , around 11 O clock he returns his home and he will take bath and haves his meals at 12 O clock without any breakfast in the morning, and he willtake a nap, around 3 O clock again he goes to his work and returns his home and have dinner at 10pm and goes to bed.
Past history :
He is known case of tuberculosis since 20years and used ATT for it
No h/o of hypertension
No h/o of diabetes
No h/o jaundice
No h/o of epilepsy
No h/o of asthma
No h/o of similar complaints in the family
No h/o of any previous surgeries or blood transfusions
Personal history :
Diet-mixed
Appetite-decreased
Sleep-inadequate
Bowel and bladder-regular
Addictions:He is chronic smoker since 18years 2packets/2days
Patient also has a habit of alcohol consumption 3-4times/week and consumes 180-360ml
Family history:
No relevant family history
Drug history :
No allergy to known drugs
General examination:
Patient of coherent,cooperative and conscious
Clubbing is seen
No Icterus
No lymphadenopathy
No pallor
No cyanosis
Vitals :
Temperature-afebrile
Bp-110/80mm/hg
Pulse rate -98beats/min
Respiratory rate -26cycles/min
Systemic examination:
CVS:s1&s2 are heard
bilaterally symmetrical chest wall
no thrills and murmurs heard.
Respiratory system: bilateral air entry present
wheeze is present
position of trachea central.
CNS: patient is conscious and coherent.
Abdomen: distended
Investigations:
Provisional diagnosis:
cor pulmonale, copd, with history of TB.
Treatment:
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