MEDICINE ELOG: 68Y/F WITH SOB

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan

COMPLAINTS AND DURATION:

Pt c/o cough: 6 months

Shortness of breath= 4-5 months

HOPI:

-Patient was apparently normal untill 6months back.

then developed productive cough, insidious in onset gradually progressive with white colored mucoid sputum , relieved on taking medication and aggrevated later I.e., cough Increased mostly at night time around 3-4AM

Shortness of breath: 4-5 monthly, insidious in onset and gradually progressed to grade-IV now. Increases on walking for few steps.
Orthopnoea present.
feels better on lying to lateral side.
Pt also gives h/o PND

PAST HISTORY:

H/o decreased appetite: 4 months.

no h/o fever/ burning micturition/ pain abdomen / chest pain/ palpitations

No Decreased urine output/ pedal edema.

Not a k/c/o DM/HTN/TB/ Epilepsy / CVA / CAD/ thyroid diseases

- H/o fall 2 years back -> Right antle # - POP applied.

PERSONAL HISTORY:

Normal appetite, mixed diet with regular bowel and bladder habits and addiction of smoking

2-3beedis/day started 8years back ,stopped 2 years back

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR: PRESENT

NO PEDAL EDEMA,ICTERUS,CYANOSIS,CLUBBING,

LYMPHADENOPATHY

VITALS ON ADMISSION:

PR-98 BPM

BP- 130/80MM HG

RR- 40 CPM

SPO2- 92% AT RA

GRBS - 133mg/dl

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT