CASE OF SOB and DECREASE URINE Output

67 yr old male came to OPD with 
Chief complaints : sob,cough, generalized weakness from 1month
Decreased urine output and pedal edema from 1 week
HOPI : pt apparently asymptomatic 1 month back then he developed sob which increased on lying down , exertion and decreased on sitting posture and rest and he has wheeze
No history of orthopnea, chest pain, PND

Cough from 1month associated with expectoration it is mucoid non foul smelling non blood stained 
He has pedal edema and decreased urine output from 1 week
Past history : similar complaints 2 years ago
Not k/c/o htn,dm,cad,tb,asthma
Personal history: 
Diet - mixed
Appetite - decreased
Bowel and bladder - regular
Habits- occasional alcoholic
             Tobacco chewing and will smoke 20 beedis                  per day
Sleep - adequate
General examination conscious , coherent , cooperative
No pallor
      Icterus
      Cyanosis
       Clubing
       Lymphadenopathy
Vitals
         BP 120/70mmhg
         PR 79 BPM
         RR 20
         Spo2 95 
Systemic examination
       Respiratory examination
        BAE +ve and normal vesicular breath sound                 heard 
        B/L crepts IN ISA
        CVS 
        S1S2 heard 
        No murmurs  heard
        Abdomen
        Soft non tender
        No hepatomegaly and splenomegaly
        CNS :. Higher motor and sensory functions are           normal 
   Investigations
         Usg
     2D echo
     
    ABG
   


Provisional diagnosis
    Acute exacerbated COPD with type 2 respiratory 
  Failure with severe PAH

Popular posts from this blog

65 yr old female with involuntary movements of Lt upper limb

pre final case

Online Blended Bimonthly Assignment MAY 2021 Roll no. 52.