55 year old male patient with complaints of sob and generalised swelling

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HISTORY OF PRESENT ILLNESS 

patient is a resident of narketpally ,owns a tea shop and prior to this he was farmer by occupation from years(20-40)later due to financial constrains and failed crops he decided to work as a construction labourer (40years),his work mainly involving with handling of  cement .later few years in he developed sob and tiredness and felt unwell ,he put up a tea stall here in narketpally (3years back ).two days ago patient was asymptomatic while travelling from Vijaywada to narketpally when he developed generalised swelling of his body ,profuse sweating ,his skin felt cold ,sob later was brought to the hospital .

PAST HISTORY 

Patient is a known case to tuberculosis (at 20 years of age )

Patient is not a known as to hypertension ,diabetes mellitus ,thryroid abnormalities .

FAMILY HISTORY 

no significant family history 

PERSONAL HISTORY 

Diet - mixed 

sleep - is adequate 

Appetite-reduced 

Bowel and bladder -regular 

Addiction-

Patient smokes on pack of biddi every two days 

9biddis/day 

Chronic alcohol consumer -since the age of 40 years 

180ml (quarter) of whiskey and brandy 

GENERAL EXAMINATION 

Patient was examined in well lit room and adequate exposure after obtaining the informed consent 

Patient is conscious ,coherent and coperative ,comfortable 

Well oriented to time ,place and person 

Patient is moderately built and moderately nourished 

Pallor -absent 

Icterus -absent 

Cyanosis-absent 

Clubbing -present 

Pedal Edema- on the day of admission B/L pitting type edema extending all over the body 

Lymphadenopathy-absent 

VITALS 

TEMP-afebrile 

Bp- 170/90 mmhg

HR-76bpm 

RR-24 beats /beats 

SYTEMIC EXAMINATION  -patients check was completely exposure 

Respiratory system 

Inspection 

Shape of chest -normal 

Trachea -central  

Has a swelling in his lumbar region 

 PALPATION 

All inspectory findings are confirmed by palpation 

Trachea – midline

Apical impulse

Chest movement

Measurement of Chest expansion – Whole/Hemi thorax expansion

Tactile Fremitus Vocal Fremitus- equal vibrations were felt