GENERAL MEDICINE E- LOG
Hi, I am Aziza Ferdose 3rd sem 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.
A 66 YEAR OLD MALE PATIENT CAME WITH COMPLAINTS OF SHORTNESS OF BREATH
A 66 yr old male patient farmer by occupation came to casualty with complains of shortness of breath since 1 day and abdominal discomfort
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 day back then he developed breathlessness sudden in onset MMRC grade 3 increased on exertion no relieving factors present
no orthopnea, palpitations, no seasonal or diurnal variation
no complain of cough, chest pain , chest tightness, fever
complain of abdominal discomfort since 3 days
PAST HISTORY
no similar complaints in the past
no past history of TB, HTN, DM, Epilepsy, asthma
past history of covid 19 1 yr back got admitted at local hospital for 15 days
patient is a known case of CAD since 10 yrs on Tab clopitab A 150 mg , tab rantac 150 mg
PERSONAL HISTORY
diet : mixed
bowel : regular
micturition : normal
known allergies : no
VITALS
temperature : Afebrile
pulse rate : 102 bpm
Bp :140/100 mmHg
Respiratory rate : 20 /min
GENERAL EXAMINATION
no pallor , icterus , clubbing of fingers , lymphadenopathy, malnutrition , oedema
CNS : concious,coherent and cooperative
CVS :s1 s2 heard
RESPIRATORY SYSTEM : BAE +, dyspnoea , no wheeze , central position of trachea, vesicular breath sounds
Inspection
shape of chest - elliptical
B/L symmetrical chest
trachea appears to be central
expansion of chest - equal on both sides
no drooping of shoulders
no crowding of ribs
no wasting of muscles
spinoscapular distance equal on both sides
Palpation
no local rise of temperature
no tenderness
chest movements equal on both sides
apex beat left 5th ICS
TVF equal in all areas
Percussion
direct - hyperresonant
indirect - hyperresonant
Auscultation
BAE +, VBS
decreased breath sound right ICA, MA, ISA, Infra SA
INVESTIGATIONS
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