50 year old patient with shortness of breath
A 50 year old male patient presented with shortness of breath , cough and pedal edema.
28 July , 2022
E LOG GENERAL MEDICINE
Hi, I am G. Sai Karthik , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.
Chief complaints :
A 50 year old male patient who was agricultural worker and shepherd by occupation came to the opd with the chief complaint of shortness of breath , cough , pedal edema along with distended abdomen.
History of present illness :
Patient was asymptomatic 6 years back, and suddenly developed shortness of breath.
Cough on and off since 3 years.
Pedal edema since 3 years.
Distended abdomen gradually progressive.
He has associated chest pain during cough.
History of past illness :
No diabetes
No hypertension
No TB
No CAD
No Syphilis
No Asthma
Family history :
No significant family history
Allergies :
No allergies
Drug history :
Medicines for cough and shortness of breath.
Personal history :
Patient was previously a farmer by occupation.
Appetite is normal
Mixed diet
Bowel movement : hard stools from a week
Bladder movement is regular.
Sleep was indequate and interuppted.
Previously alcoholic but stopped 1 year back
Regular smoker - a packet daily.
PHYSICAL EXAMINATION :
A. General Examination
Conscious , coherent and cooperative
Well built
Dehydrated - mild
Pallor is absent.
Icterus is absent.
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is present
Vitals :
Temperature: 96.6 F
Pulse: 82
Respiration: 22/min
Blood pressure: 110/70 mmhg
Spo2: 96%
PHYSICAL EXAMINATION :
A.Cardio vascular system :
Cardiac sounds : S1 and S2
No thrills
No murmurs
B.Respiratory system :
Dyspnoea : present
Wheeze : present
Position of trachea : centre
Breath sounds : vesicular
C.Abdomen :
Shape of abdomen : distended
No tenderness
No palpable mass
No palpable liver
No palpable spleen
Ultra sound
ECG
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