A 45 year old male came to the OPD with generalized weakness and mild SOB since 5 months

This is an elog that contains the de-identified health data of this patient which was collected after taking the patient's informed consent for the purpose of clinical discussion.

HOPI
Patient was apparently asymptomatic 5 months ago when he developed fatigue which was insidious in onset, gradually progressive and associated with mild shortness of breath, especially on prolonged exertion.
Patient came to the OPD 4 days ago because of worsening of symptoms and limitation of daily activities.
Patient also complains of severe pain in the heels of both legs on walking since one year.

PAST HISTORY
No history of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy or cardiovascular disease.
No history of previous surgeries.

FAMILY HISTORY
No significant family history.

PERSONAL HISTORY
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bladder: No urinary symptoms.
Bowel movements: Normal
Addictions: No addictions

GENERAL EXAMINATION

Patient was explained regarding the procedure of examination and consent was obtained. Patient was examined in a well lit room.
Patient was conscious, coherent and cooperative at the time of examination. He was well oriented to time, place and person.
Build: Moderate
Nourishment: Moderate
Pallor: present ++
Icterus: Absent
Clubbing: Absent
Cyanosis: Absent
Lymphadenopathy: Absent
Edema: Absent
 
VITALS
PR: 76 bpm, regular rhythm, normal volume, good character of vessel wall, no radio-radial delay, no radio-femoral delay.
BP: 120/80 mm of Hg, taken on the left arm in sitting position.
RR: 14 cpm
Temperature: Afebrile to touch.




SYSTEMIC EXAMINATION

CVS: 

Inspection: Symmetrical shape of the chest,  No scars, visible pulsations, no prominent venous collaterals. No clubbing of fingers or toes. Adequate dental hygiene. No splinter hemorrhages in the nail beds. No signs of cardiac disease. 
Palpation: Inspectory findings confirmed. Apex beat was felt. No abnormal displacement or "double thrusts".
Percussion: Resonant notes heard.
Auscultation: S1 and S2 heard. No heart murmurs appreciated. No crackles heard.

Respiratory: Bilateral air entry present. Normal vesicular breath sounds heard. No adventitious sounds heard.
CNS: Higher mental functions intact, no focal neurological deficits.
PA: Soft, non tender abdomen. No organomegaly. No visible pulsations.


INVESTIGATIONS

PROVISIONAL DIAGNOSIS
 
TREATMENT




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