A 55 Yr old man presented with shortness of breath since 21 days and swelling of both lower limbs since 11days

January 05, 2023

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A 55 Yr old male presented with shortness of breath since 21 days and swelling of both lower limbs since 11 days

History of presenting illness :

Patient was apparently asymptomatic 2 years back then he developed Shortness of breath while lifting weights then 21days back started to develop SOB even while doing normal work and occasionally it used to present while taking rest or on lying down , walking and relieved to some extent in sitting position.

Patient also complains of Pedal Edema from 11 days back which is insidious in onset gradually progressed till knees

History of facial puffiness 1 week back and it is resolved .

history of backache for the past 5years which was non radiating ,non progressive relived with rest and started to take NSAID medication every 2-3 days for the past 3years .

No history of chest pain , palpitations , sweating

No history of fever , cold , cough

No history of burning Micturition , frothy urine , Hematuria

No history of decreased urine output

History of past illness :

Not a known case of Diabetes Mellitus , Hypertension , Asthma , TB , CAD , CVA , Epilepsy

Underwent surgeries for hernia right side 8 years back and hernia left side 4 years back .

Personal History :

Patient takes mixed diet , appetite is good , bowel and bladder movements are regular , sleep is disturbed .

He consumes 90 mL whiskey daily from past 10 years and chewing gutka for the past 15 years

Daily routine :

Patient wakes up around 6 in the morning and goes out around 7 and has his breakfast around 10 am , continues to work and around 2 am he comes home and sleep for an hour or 2 and resumes his work in vegetable Market till 9 pm . Later he drinks 90 mL whiskey and comes home , have dinner and sleep around 10 pm .

Family history :

His mother and elder brother had similar complaints of Shortness of breath .

Treatment history :

Patient used NSAIDS for back pain every 2-3 days for past 3 years .

GENERAL EXAMINATION

Patient is examined in well lit area After taking consent

Patient is conscious , coherent , cooperative , well oriented to time , place , person .

Patient is moderately built and moderately nourished .

Pallor - present