A 63 yr old male patient came with complaints of chest pain and SOB since 2 days

 A 63 year old male patient , resident of narketpally,labourer by occupation came with CHIEF COMPLAINTS: 

CHEST PAIN SINCE 2 DAYS

SHORTNESS OF BREATH SINCE 2 DAYS

HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 2 days ago then he developed CHEST PAIN - Heaviness in the chest,insidious in onset,dull type of pain on exertion radiating to left hand and shoulder since 2 days

SHORTNESS OF BREATH was sudden,not progressive,grade 2(nyha), aggregating on exertion, relieving on resting since 2 days

H/o easy fatigability since 2 days

No h/o giddiness,nausea, vomiting , headache, sweating 

No h/o extertional dyspnea,orthopnea,paroxysomal nocturnal dyspnea, palpitations,postural hypotension

No h/o pedal edema

No h/o burning micturition , decreased urine output

No h/o blurring of vision,tingling sensation,numbness

PAST HISTORY: HYPERTENSIVE SINCE 6years on medication Amlodipine

Diabetic since 6years on medication Metformin

No h/o Asthma, epilepsy,thyroid disorders,TB

CAD,CVS

FAMILY HISTORY: NOT SIGNIFICANT

PERSONAL HISTORY: 

DIET-MIXED

APPETITE - NORMAL

SLEEP- ADEQUATE

BOWEL AND BLADDER MOVEMENTS: REGULAR

ADDICTIONS - NO

GENERAL EXAMINATION:

Patient is conscious , coherent, cooperative.Well oriented to time place person.Moderatley built, moderately nourished

PALLOR: Absent 

ICTERUS:Absent

CYANOSIS:Absent

CLUBBING:Absent

PEDAL EDEMA:Absent

LYMPHADENOPATHY :Absent

VITALS:

BP:120/80

PR:75bpm

CVS:S1S2 heard,no murmurs heard

RS:BAE+

JVP: SLIGHTLY ELEVATED

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

INSPECTION:

Apical impulse not visible

No precordial bulge

JVP - SLIGHTLY ELEVATED

PALPATION:

ALL INSPECTORY FINDINGS WERE CONFIRMED

Trachea : central

Apex beat : Medial to midclavicular line

No palpable murmurs

AUSCULTATION:

S1S2 Heard

No murmurs

INVESTIGATIONS:


PROVISIONAL DIAGNOSIS:

?RIGHT HEART FAILURE


Comments

Post a Comment

Popular posts from this blog

CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH

Title: My Journey in the General Medicine Department: A Student's Perspective (2018-2023) CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT Introduction: Embarking on my journey as a medical student in the General Medicine Department in 2018, I was filled with a mix of excitement, curiosity, and a deep sense of purpose. Over the course of five transformative years, I had the privilege of immersing myself in the world of medicine, witnessing the triumphs, challenges, and profound impact of healthcare on patients' lives. In this blog post, I will share a detailed account of my journey in th...
Read more

65 yr old patient with pain in lower abdomen and Shortness of breath

Image
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, ...
Read more

A 14yr old girl came to opd with complaints of Shortness of breath

A 14 yr old girl came to opd with CHIEF COMPLAINTS : Shortness of breath since 2 days  Vomitings since 2 days Fever since 2 days History of presenting illness: Patient was apparently asymptomatic 2days ago thn she developed Shortness Of Breath which was insidious in onset, gradually progressive from grade 1 to grade 4,not associated with orthopnea,PND FEVER which was insidious in onset, high grade ,continuous,no diurnal variation associated with chills n rigor VOMITINGS which was 
Read more