70 year old male came with chief complaints of shortness of breath





A 70 years old male Patient came with chief complaints of shortness of breath since 1week.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 years back then he developed hypopigmented patches on his body.After a year they consulted doctor and he was diagnosed with hansens disease .he developed reabsorption of toes. There was numbness and loss of sensation since 10 years.He complains of Shortness of breathe since 1week increases on exertion and left sided chest pain.he also has blurring of vision in left eye since 1year and was diagnosed with cataract.he also complains itching over the body.


DAILY ROUTINE

Patient was to work in their paddy field 6 months ago then he stopped working and he is doing minimal house hold work with his his wife.he wakes up at 4 AM in the morning and complete his daily routine and helps his wife in household chores.he ll have his breakfast around 8AM and has his lunch around 1PM (he mostly eat dal or curry with chapati) and has his dinner-at 9PM and he ll watch tv upto 10 PM and he ll go to bed at 11PM


PAST HISTORY

Not a known case of Diabetes,HTN,asthma

Had an accident caused due to machine where he lost his upper part of phalanges of left hand.


PERSONAL HISTORY

Diet-mixed

Appetite-Normal

Bowel and bladder- normal voiding of urine and decreased bowel movement since 10 days

Sleep - inadequate(5-6hrs)

No addictions

FAMILY HISTORY 

No significant family history 

GENERAL EXAMINATION 

Pallor-absent

Icterus-absent

Clubbing-absent

Cyanosis-absent

Lymphadenopathy-absent

Edema-absent


VITALS

Temperature-afebrile

BP-120/80 mm hg

HR-80bpm

RR-18cpm


SYSTEMIC EXAMINATION 

Cardiovascular system:S1 and S2 heard

Respiratory system:

Vesicular breath sounds heard

Trachea central in position 

Abdominal examination:on inspection:Normal

On palpation:No tenderness is seen

Central nervous system:loss of sensation over both lower limbs and forearms

Deformity of hand

Resorption of 3rd ,4th,5th digits of toes

INVESTIGATIONS

2D echo

RFT

ECG

LFT

GRBS

CBP

CUE

PROVISIONAL DIGNOSIS

Hansen’s disease for evaluation with severe mitral regurgitation 

TREATMENT 

TAB TECZINE 10mg OD. (AT NIGHT) X 1WEEK

TAB LASIX 20 mg OD X 1WEEK

TAB ECOSPRIN AV 75mg OD X 1WEEK

TAB MET XL 25mg OD X 1 WEEK

E OINTMENT CIPLOX BD 5DAYS


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