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

 Hi I am Madhuri palsa ,6th sem medical student .this is an online e blog to discuss our patients deidentified health data shared after taking his /her /guardian signed informed consent 

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 23 year female with fever and productive cough

Image
Hi, I am P.Madhuri 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. 
Read more

A 50 year female patient with viral pyrexia

Image
a 50 years old female patient with viral pyrexia  August 23, 2022 Iam P.Madhuri,3rd semester medical student.this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.    Chief complaint: A 50 years old female patient came with fever and pedal edema. History of present illness: the patient was apparently asymptomatic 1 week back. She had fever since 1 week and said that there was increased temperature at night and diurnal variation in temperature. She had pedal edema since 1 week.she was suffering with constipation since 2 years, passing stools once for 3 days. she had vomiting and loose stools with mucous 6 times ,with no blood 1 week back. She is also complaining of burning micturition since the time of fever.  History of past illness: no history of hypertension,diabetes mellitus,epilepsy,CAD,tuberculosis, thyroid,asthma. Under went hysterectomy. Personal history:  Appetite: normal Bowels:
Read more