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 


Comments

Post a Comment

Popular posts from this blog

A,40 year old male patient came to general medicine OPD with chief complaints of decreased urine output

Image
3-1-23 Hi, I am kalpak Mawale  of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition.  40 year old male patient who is an advocate came to general medicine with cheif complaints of decreased urine output since 8 days. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 5years back then developed decreased urine output since 8 days and underwent dialysis at out hospital Sai sanjeevini .He had Renal tubular acidosis and right hip joint fracture. HISTORY OF PAST ILLNESS   Chronic kidney disease on maintenance heamodialysis since 11 years,hypertension since 5 years . No history epilepsy,TB,asthma ,diabetes,CAD. Surgical history-right hip joint surgery 10 days back. FAMILY HISTORY - no relevant family history PERSONAL HISTORY Di
Read more

A 35 year old man with hypo-pigmented patches

Image
A 35 year old married man, working as a tractor driver, resident of Bhongir came to medicine OPD with Chief complaints of increase in size of the discolouration of skin since 8 months History of Present Illness- The patient was apparently asymptomatic 8 months ago and suddenly noticed heat rashes over the nose area. It was not itchy. The rash persisted for 15 days. The skin started peeling off of the rashes with skin hypopigmentation and mild pain. After 10 days, he decided to consider herbal medicine and took it for 15 days which was not of any help. The patches kept spreading to his chest, upper limb and legs over the next 15days. The skin peeling continued and was associated with fever in the evenings after coming back home from work. He went to a local doctor and took medicine with saline administered for 3months. The fever subsided on medication with decrease appetite(no significant weight loss) and burning sensation and itchiness over patches and headache over the bitemporal reg
Read more

28 year old women with pain and weakness right upper and lower limb

A 28 year old married woman, farmer by occupation, resident of kunjbihar came to medicine OPD with chief complaints of Pain and weakness in upper and lower limbs since 8 years History of Present Illness - The patient was apparently asymptomatic 8 years ago, then had a sprain with sharp pain in the right hip region while drawing water from well. It was sudden in onset and dragging type of pain. Radiating towards  lower back and slowly spread to right upper limb amd lower limb. Pain aggravated on movement i.e., after work in the nights and relieved on medication, massage and rest. In the last 3 years, weakness has increased and she was not able to perform normal household works. She went to an orthopedicean 3 years ago, pain was relieved on medication, so she discontinued taking medicine, which brought back the pain. Later, she was asked for investigation like blood and x ray. The doctor saw the result and asked her to consult a neurologist, which they didn't consult. She then came
Read more