A 72 YEAR OLD MALE WITH SOB WITH COUGH
This is an 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.
Unit posting (Intern 2018).
MEDICAL WARD
GM II
DR Nikitha
DR Haripriya
DR Govardhini
DR Hemanth.
A 72 year old male came to casualty with chief complaints of
CHIEF COMPLAINTS:
Shortness of breath since 8 days.
cough since 5 days.
Drowsiness from past 5 hours.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 8 days ago then he developed -
> SOB-
Since past 8 days [it was mild sob] grade-I, But from past 3 days it was [moderate-severe] grade II-III.
It was sudden in onset [ he said that, when it was started he was in sitting position], And aggravates on walking and relieved on lying down,continuous, non-progressive.
It is not associated with chest pain, No decreased urine output.
No h/o palpitations,excessive sweating ,burning micturation,fever,vomitings, abdominal pain,loose stools.
> COUGH-
Since 5 days.
It was sudden in onset, intermittent in nature not associated with expectoration. Non-productive cough.Aggravated on walking and relieved on rest.
No h/o seasonal variation, not associated with cold,
> Pedal edema-
Since 2 days.
Pitting type.
Upto ankle length.
PAST HISTORY :
- No h/o similar complaints in the past.
- k/c/o hypertension since 5 years. (on medication Telma 40 mg PO/OD)
- No h/o HTN, DM II, TB, Bronchial Asthma, Epilepsy, CAD, CVA.
- He has a h/o chronic smoking ( Daily 2 packets) and alcohol intake ( daily 90 ml) from past 50 years.
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