General medicine case-07
Nov 30 2021
Hemogram:-
APTT
PT:-
ECG :
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A 60 year old male patient who is a farmer by occupation came to opd with cheif complaints of distended abdomen and shortness of breath .
History of present illness:-
Patient was apparently asymptomatic 11 years back then he developed sudden onset of chest pain which was associated with sweating and was diagnosed as CAD and was on regular follow up. 3 months back patient noticed abdomen distension associated with shortness of breath and went to local hospital and got treated.Then 8 days back he was having shortness of breath ,fever which was associated with chills and also he was having cough and also neck pain for which he came to our hospital.patient had h/o hematemesis 5 days back.He was also complaining of neck pain from 5 days.
Past History:-
Patient is known case of hypertension and diabetes since 8 years and he is on regular medication.
Personal history:-
Patient has normal eating habit with mixed diet.
He was an alcoholic 11 years back but he stopped drinking from 8 years.
He is smoker also before 11 years but now he stopped it from 5 years.
Loss of apetite.
Sleep normal.
Bowel and bladder movements normal.
Family history:-
No significant family history.
General examination:-
Patient is conscious ,coherent ,cooperative .
Pallor present.
No pedal edema.
No cyanosis,clubbing,icterus.
Vitals:
Temperature-Afebrile.
Pulse rate -80beats/min.
Respiratory rate-18cycles/min.
BP-100/70 mm/hg.
Systemic examination:-
CVS-S1,S2 heard.
CNS:-He is conscious.Speech is normal.No abnormalities detected.
Abdomen-Distended abdomen.
Chest xray:-
CUE:-
