A 75 year old male with complaints of SOB since yesterday

 A 75 yr old male ,resident of suryapet,lorry driver by occupation came with 

CHIEF COMPLAINTS: SHORTNESS OF BREATH since yesterday

HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 1week ago thn he developed FEVER which was insidious in onset,high grade, intermittent,with diurnal variation,no seasonal variation relieved on medication not associated with chills and rigor,rashes,nausea, vomiting, headache,blurring of vision,body pains,joint pains

COUGH with sputum insidious in onset, continuous,productive,blood tinged non purulent,mucoid type scanty in amount,with diurnal variation not associated with chest pain, abdominal pain

SHORTNESS OF BREATH which was insidious in onset, gradually progressive from grade1 to grade 4 associated with paroxysomal nocturnal dyspnea

No h/o orthopnea,chest tightness 

No h/ o chest pain, palpitations, sweating

No h/o pedal edema

No h/ o decreased urine output,burning micturition

PAST HISTORY: Known case of TB since 10 yrs taken ATT medication 

Not a known case of DM,HTN,Asthma, epilepsy,CVA,CAD

No h/o past surgeries

FAMILY HISTORY:Not significant

PERSONAL HISTORY:

DIET:mixed

APPETITE:normal

SLEEP: adequate

BOWEL AND BLADDER MOVEMENTS: Regular

ADDICTIONS: ALCOHOLIC stopped 10 yrs ago(90ml per day for alternate days)

                           SMOKER stopped 10 yrs ago(Half pack (10) per day)

GENERAL EXAMINATION: 

Patient is conscious, coherent, cooperative.well oriented to time place person, moderately built moderalety nourished

PALLOR :PRESENT

ICTERUS:PRESENT

CYANOSIS:ABSENT

CLUBBING:ABSENT

PEDAL EDEMA: B/L grade 1 pitting type of pedal edema below knee

LYMPHADENOPATHY 

                SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

INSPECTION:

SHAPE : B/L symmetrical(ELLIPTICAL)

TYPE: ABDOMINOTHORACIC

MOVEMENT:b/L symmetrical

No supraclavicular hallowing

No scars,sinuses,engorged veins

No swellings

No winging of scapula ,no crowding of ribs

No spine abnormalities

APICAL IMPULSE : not seen

PALPATION:

ALL INSPECTORY FINDINGS WERE CONFIRMED BY PALPATION

No local rise of temperature no tenderness

EXPANSION OF CHEST: 

APICAL : decreased movements on right side

ANTERIOR: Decreased movements on right side

POSTERIOR: Decreased movements on right side

APEX BEAT: Not clearly felt( might be due to mediastinal shift)

TRACHEA:Deviated to right side

Transverse diameter is more than AP diameter

TACTILE VOCAL FREMITUS:

                                   supraclavicular,Infraclavicular,Mammary,Inframammary,Axillary,Infra Axillary

Suprascapular,Infrascapular,Interscapular : all areas on right and left side are resonant

PERCUSSION:

Right side:resonant till 5th intercoastal space ,dull ness from 6th (liver)

Left side: Resonant till 7th intercoastal space ,dullness from 8th(spleen)

AUSCULTATION:

Breath sounds heard on tracheal region

Vesicular on lung parenchymal region

ADDED SOUNDS:B/L diffuse crepitations heard

TACTILE VOCAL RESONANCE:

All 9 areas are equally heard Resonant 

INVESTIGATIONS:

ULTRASOUND ABDOMEN

RPD 3 CHANGES

PROVISIONAL DIAGNOSIS:

                      CKD ON MHD(Maintenance hemodialysis)







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 ; 
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