65 yr old patient with pain in lower abdomen and Shortness of breath
A 65-year-old male patient who is a farmer once(stopped working 6 years back)came to the medical OPD with the
Date of history taking:- 5/12/22
Date of examination:- 5/12/22
CHIEF COMPLAINTS:-
Pain in the lower abdomen since 8 days
Shortness of breath since 8days
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asyptomatic 8days back then he experienced diffuse pain all over the abdomen which was insidious in onset and was not radiating and relieved on temporary medication ( drug - unknown; dose unknown; indication - unknown ) character of pain (?)
He also developed shortness of breath 8days which was insidious in onset grade 3 ( sob on normal physical activity) which was relieved on medication ( drug unknown; dose - unknown)
It is associated with productive cough ( which has mucous as content scanty in quantity; white in colour; and no foreign bodies)
fatigue; sweating ;
NO H/O of Hematemesis, Malena, Vomiting, Nausea H/O bulky stools, black tarry, and clay-coloured. H/O Jaundice, pruritus
NO H/O fever with chills
NO H/O anorexia
NO H/O orthopnea, palpitations
NO H/O frothy urine
NO H/O haematuria, oliguria
NO H/O blood transfusions
NO H/O tattoo marking
NO H/O loss of weight
NO H/Ohistory of palpitations
No H/O fever, or joint pains.
PAST HISTORY:-
History of pulmonary TB 25 yrs back
No history of DM
No history of Hypertension, asthma, epilepsy, TB
No history of prolonged hospital stay
No history of previous surgeries
PERSONAL HISTORY:-
Appetite - Reduced since 1 year
Diet - Mixed
Bowel and Bladder - Regular
Sleep - inadequate
Addictions - stopped 20 years back, before alcohol and smoking
FAMILY HISTORY:-
None of the patient’s parents, siblings, or first-degree relatives have or have had similar complaints or any significant co-morbidities.
ALLERGIC HISTORY:-No allergies to any kind of food or medication.
Asthma/COPD/ CAD/ Blood transfusions
Any surgeries, drug usage, allergies.
HIGH ARCHED PALATE
GENERAL EXAMINATION:-
A 65 old male patient, supine decubitus who Is conscious, coherent and cooperative comfortably seated/lying on the bed, well-oriented to time,place and person
There is Pallor
No, Icterus, cyanosis, clubbing
generalized lymphadenopathy and no pedal edema
Pulse: Rate, rhythm(regular)character(normal ), volume :- low
Afebrile
BP- 120/80mmHg
PR-76bpm(Pulse: Rate, rhythm(regular)character(normal ), volume :- low )
RR-20cpm(type- Abdomino thoracic)
SpO2-98%
GRBS-98mg/dL
CVS-S1S2+
RS-BAE+
PA-soft, tenderness at Rt hypogastrium and left lumbar region
CNS-NFD