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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