A 75YR OLD MALE, CARPENTER CAME TO THE CASUALITY WITH C/O BREATHLESSNESS SINCE 3 DAYS AND BOTH LOWER LIMB SWELLING SINCE 2 MONTHS PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YRS BACK THEN HAD SOB WORSENED OVER DAYS, ATTENDED TO A MEDICAL FACILITY AND DIAGNOSED WITH ? HEART PROBLEM AND HYPERTENSION SINCE 5 YEARS, PATIENT HAD EASY FATIGUABILITY, SOB ON EXERTION WHICH INTERFERES WITH HIS WORK SINCE THEN HE STOPPED WORKING AND STAYS AT HOME. SINCE 1 MONTH, PATIENT HAD SOB AND COUGH ON EXERTION WHICH HAD WORSENED IN LAST 3 TO 4 DAYS TO SOB AT REST. NO H/O FEVER, NO CHEST PAIN, NO PALPITATIONS, ADMITTED ONE MONTH BACK FOR HEART FAILURE AND AKI ON CKD K/C/O HTN SINCE 15 YRS, CURRENTLY ON T. AMLONG 10 MG BD ? CAD +, EF 40% K/C/O CKD SINCE 1 TO 2 YRS ON CONSERVATIVE MANAGEMENT K/C/O ? COPD ON ASTHALIN INHALER SINCE 1 YR PERSONAL H/O: SLEEP IS ADEQUATE APPETITE IS NORMAL BOWEL AND BLADDER MOVEMENTS ARE REGULAR NO KNOWN ALLERGIES SMOKES 1 PACK BEEDI SINCE 50 YRS FAMILY H/O: NO SIGNIFICANT FAMILY
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NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. A 54 yr old male, govt service employee by occupation, resident of west bengal, came for regular checkup Patient was apparently asymptomatic until 25yrs ago them he had symptoms of headache, giddiness, for which he went to a doctor and was diagnosed with hypertension, once medications were started, bp came under control In 2000, he stopped medication for 15-20 days again he c/o lightheadedness, neck stiffness, and his tongue was rolling backward (tongue spasm). After this happened 2-3 times, he was hospitalized for 1 day. 16yrs ago, at the age of 38, he had wt loss and on general checkup, found out his