A 70 year old male patient presented with SOB , cough and fever

General medicine 
Hi i am KALPAK MAWALE 3rd sem 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 patients' clinical problems with collective current best evidence-based inputs

Chief complaint -
70 year old male patient farmer by occupation came to hospital with complaint of breathlessness, dry cough, fever

History of present illness-
Patient was asymptomatic 1 week ago then he developed SOB with cough and fever.
SOB is present in rest and more in night
He also experienced SOB by walking short distance.
He developed cough 1 week ago
Cough is non productive (dry cough) which is disturbing patients sleep.
Fever is also present along with SOB
But fever was reduced 3 days ago also by taking medicine 

HISTORY OF PAST ILLNESS-

The patient had history of similar complaints in the past.Since the past 15 years he was experiencing the symptoms of breathlessness and cough occasionally once a year for which he was treated conservatively by the local RMP.

The patient was diagnosed 1 year ago for heart failure for which he is taking medicines

The patient was known to be hypertensive since 1 year for which he is on regular medication

The patient had a history of road traffic accident 2 years ago which lead to a deformity in his spin injury 

PERSONAL HISTORY-

DIET: Mixed
APPETITE : Normal
BOWEL AND BLADDER: Regular
SLEEP: Adequate
ALLERGIC HISTORY: No known allergies

Alcohol: Occasionally consumed beer with toddy.Stopped 3 years ago

Tobacco:Chronic Cigarette smoker.Started smoking since he was 17 years old.Smokes 2-3 beedis per day.Stopped smoking since he started experiencing SOB

DRUG HISTORY:

Tab.Rovastatin
Tab.Clopidogrel
Tab.Aspirin
Tab.Finofibrate

FAMILY HISTORY-

No significant family history.

GENERAL EXAMINATION-
Conscious and cooperative 
Coherent
Moderately build
No pallor
No icterus
No cyanosis
No lymphadenopathy 
No Pedal edema

VITALS-

TEMPERATURE:Febrile(100 degree Fahrenheit)

PULSE RATE:88 bpm

BLOOD PRESSURE:110/70 mm Hg

SpO2:98%

GRBS:101mg/dL

SYSTEMIC EXAMINATION-

CVS:S1 S2 Heard,no murmurs 

RESPIRATORY SYSTEM:

No scars are seen on inspection

Shape of the chest:

Tracheal position:Centre

Bilateral Chest Movement 

Tracheal position is confirmed by palpitation

Dyspnea present (CLASS 4 NYHA CLASSIFICATION)

Wheeze present

Breath sounds are Vesicular

CNS:Higher motor functions intact

P/A:Soft,Non tender,BS+

INVESTIGATIONS

INVESTIGATIONS CHART-
Clinical diagnosis -  chronic bronchitis 


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