CASE 1 THESIS

C/o  Shotrness of breath 1 week
Cough 1week 
B/L pedal edema 1 week.

History of presenting illness 
49year old male works as a shop keeper in gold shop  was apparently Asymptomatic 7 days ago then he developed B/L Pedal edema pitting type insidious in onset gradually progressive 
Breathlessness since 1 week grade 3 to 4 NYHA associated with cough without expectoration  initially he went to near by hospital there his GRBS is 610 mg/dl they suggested them to go to KIMS 
No h/0 fever vomiting diarrhoea 
No h/o chest pain palpitations

10 years back he came to hospital for Rt hypochondriac pain  initially evaluated and managed drs told them some liver problem (No previous documents available)
8 years back he started loosing weight nearly 8 to 10 kgs in 1 to 2 months duration doctors told them he was Diabetic 

Past history

Diabetes since 8 yr TAB METFORMIN500 mg 
N/k/c/0 HTN CAD ASTHMA EPILEPSY


Personal history

Occupation: He works in gold shop as a shop keeper

He drinks 1 quarter alcohol almost everyday since 15 yrs and every night when he drinks he doesn't eat any food

General examination :

Pt is c/cc
Pallor present
B/Lpedal edema present 

Vitals
BP 110/70 mmhg
PR 82bpm
RR 20 cpm



CVS
Auscultation s1 s2 heard
Mid diastolic murmur present
Resp system
Bilateral air entry present
P/A soft , non tender

Investigations

On 28/12/23

29/12/23


30/12/23

Chest X ray


Fever chart


Usg abd and pelvis 


ECG














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