GENERAL MEDICINE 8
A 70 YEAR OLD MALE PATIENT COME TO THE CHIEF COMPLAINT OF SHORT NESS OF BREATH.FEVER.COUGH
Hi I'm Soniya , 3rd sem medical student .This is an online elogbook to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE STUDY
C.C A 70 year old male patient. agriculture by occupation resident of Haliya come to the chief complient of
Short ness of breath since 6 days
Fever since 6 day
Productive cough since 6 days with chest pain
HoPI;
Patient was apparently asymptomatic 15 years ago then he developed cough which is dry and breath less ness are present they are seasonal and diurnal variation(night >mrg)
In winter they are more common
Since 3 years breath less ness showed no seasonal variation
Sob is aggressive during agriculture activity relived by rest
Patient had aknown history of road traffic accident 1 year ago (spine deformity)
Later he developed hypokinesia ( CAD ) he is on anti platelet medication such as clopidogril
Then he developed cough with sputum since 6 days
Sob since 6 days
Fever since 6 days
PAST HISTORY
Similar complaint are present in the past
Hypertension since 1 year
Hypokinesia since 1 year
No daibetes . epilepsy .asthama.TB
FAMILY HISTORY
No significant
PERSONAL HISTORY
Appetite normal
Mixed diet
Bowel blader movement are normal
Micturition normal
Smoker started at 17 years and stopped since 6 days
Alcoholic
Drug history
Tab rosuvastatin10 mg
Tab Fenofebrate 60 mg
Tab clopidogril 75 mg
Tab aspirin 75 mg
Physical examination
Patient was concious coherent cooperative
No paller
No icterus
No cyanosis
No clubbing of fingers
No pedal edema
No lymphadenopathy
Dehydration mild
PR 80 BPM
RR : 22cpm
BP 140/ 90 mm of hg
Temperature 98.8'c
Spo2 95% in sitting 98% in supine position
SYSTEMIC EXAMINATION
CVS:
S1 S2 are heard
No murmur
Jvp is normal
Respiratory system
Dyspnoea present
Wheez present
Position of trachea central
Breath sounds are vesicular
No scar s .
Anteroposterior diameter 82 cm
Horizontal diameter 40 cm
Bilateral chest movement
ABDOMEN
Shape of abdomen scopoid
No palpable liver
No palpable spleen
No free fluid
Bowel sounds are present
CNS:
concious coherent
Higher motor functions intact
Daignosis: chronic bronchitis
