A 51year old male patient came to opd with chief complaints of shortness of breath since 2 months

 Hi, I am Pooja Jammula  , 6th  Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 



CHIEF COMPLAINTS 

51M farmer by occupation , resident of nalgonda ,came to opd with c/o shortness of breath since 2 months


HOPI 

Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III)

No h/o constipation , nausea , vomiting ,burning micturation 


PAST HISTORY :

N/k/c/o DM , HTN , CAD,TB, epilepsy , thyroid disorders 


FAMILY HISTORY : 

not significant 


PERSONAL HISTORY : 

Decreased apetite 

Mixed diet 

Decreased bowel movements 

Normal micturation 

No known allergies 

Alcoholic since 3 yrs 


GENERAL EXAMINATION :

I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room. 


- patient was conscious, coherent and cooperative

- well oriented to time, place and person

- well built and adequately nourished

- pallor present 

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- pitting type pedal






VITALS :

Temperature :  afebrile

BP :  100/70 mmhg                       

Pulse rate : 100/min

Respiratory rate : 16/min

SPO2 : 98% RA


SYSTEMIC EXAMINATION :

CVS : 

S1S2 +

Cardiac murmurs heard

No thrills

RS : 

Position of Trachea - central

BAE +

NVBS +

P/A :

Soft , Non tender

CNS :

NFND

PROVISIONAL DIAGNOSIS: anemia secondary to blood loss

Comments

Post a Comment

Popular posts from this blog

A 26 year old male patient presented with chronic diarrhoea

Image
Hi, I am Pooja Jammula  , 3rd Sem Medical Student.This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.” I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  CHIEF COMPLAINTS Chronic diarrhoea since 20 days HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 2 months ago,
Read more

A 27 year old female with fever and productive cough

Image
Hi, I am Pooja Jammula 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. CHIEF COMPLAINT: A 23year female patient who is a worker came to the casualty on 15thof July with complaints of high fever with chills and productive cough. HISTORY OF PRESENT ILLNESS: The patient had a fever spike so came for consultation.she again had a fever spike that is resolved spontaneous then she had no fever spikes. She underwent hemogram on 10 august no fever spike from 10 august. HISTORY OF PAST ILLNESS: No history of similar complaints in the past. Not a K/C/O HTN/T2DM/ASTHMA/CAD/CVA/EPILEPSY/TYPHOID head ache occasionally that is relieved by medications Tubectomy 3 months ago Hypothyroidism during pregnancy. PERSONAL HISTORY: DIET:Mixed APETTITE:
Read more

40F paralysis in left upper and lower limb since 2 years , cough since 4 days

Image
Hi, I am Pooja Jammula  , 6th  Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  CHIEF COMPLAINT A 40 year old female patient cane to the opd with chief complaints of paralysis in left upper and lower limbs since 2 years and Bilateral blurred vision since 2 ywars and Cough since 4 days HOPI The patient was apparently asymptomatic 2 years ago then she devloped paralysis in left upper and lower limbs which was sudden in onset associated with blurred vision.She then developed cough 4 days ago which was not associated with sputum. No complaints of headache No complaints of dizziness  No sinusitis  No h/o loss of consciousness  No complaints of chest pain, palpitations, SOB No complaints of pain abdomen, vomitings, loose stools, burning micturition PAST HISTORY  patient is k/c/o HTN since 2 years N/k/c/o DM, bronchial asthma, epilepsy, Tb, thyroid disorders FAMILY HISTO
Read more