A 50year old male with Shortness of Breath, ascitis, pedal edema and facial puffiness
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A 50 year old male who is a shepherd from Keshavapuram came with complaints of Shortness of breast from 6years, cough from 4years and abdominal distension, pedal edema and facial puffiness from 3years
History of presenting illness:
He was apparently asymptomatic 6 years ago.Then he developed shortness of breath on exertion(running) grade 1 which now progressed to grade 2. He also has cough from 4years which is productive(yellow coloured sputum). He developed abdominal distension, followed by pedal edema(upto below knee) and facial puffiness 3years ago. He went to a doctor and he was prescribed medication(unknown) and edema reduced for a year and the reappeared 2years back.
Past history:
He is not a known case of Diabetes, hypertension, asthma, CAD, epilepsy, thyroid disorders
Family history:
No member of the family similar complaints
Personal history:
He has normal appetite, takes mixed diet, he is passing hard stools from 10days, bladder movements are regular(passing frothy urine) and he smokes 1pack of beedi everyday from 30years and smokes cigarettes occasionally, used to take alcohol(200ml) everyday for the past 30years and quit drinking alcohol from april2022.
Daily routine:
He wakes up at 5am in the morning and works in the animal shed and eats his first meal at 10am. Then he goes to farm and works in the farm until 6pm and returns home. Then he have his 2nd meal of the day at 9pm in the night and goes to sleep at 10pm.
General examination:
Patient is conscious, coherent and cooperative
He is well built and nourished
Vitals:
Temperature: Afebrile
Pulse rate: 88bpm
Blood pressure: 130/70mmHg
Respiratory rate:
SpO2:96%
GRBS:205mg%
No pallor, icterus, cyanosis, clubbing, lymphadenopathy
Bilateral pedal edema is present
Systemic examination:
Respiratory system:
Inspection: Wheeze is heard
Pectus excavatum type of chest
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Palpable sounds are felt
Percussion:
Resonant note present in all lung areas
Ascultation:
Rhonchi is heard
Crepts are present
Per abdomen:
Inspection:
Abdominal distension
No scars, sinuses, masses visible
Umbilicus everted
Caput medusae is present
Palpation:
Inspectory findings are confirmed
No Tenderness
Shifting dullness:present
Percussion:
Resonant note all over the abdomen
Auscultation: Normal bowel sounds heard
No bruit heard
Cardiovascular system:
Inspection : Bilaterally symmetrical chest present
No scars, sinuses
No visible pulsations
Palpation:
Inspectory findings are confirmed
Apex beat normal
On Auscultation :
S1 S2 heard
No murmurs or additional heart sounds
Central nervous system:
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
Provisional diagnosis:
Chronic liver disease? with Right heart failure
Investigations:
Chest X ray
USG abdomen:
2D ECHO
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