General Medicine E log 6

A 70 year old patient  presents with shortness of breath and non productive cough since past 1 week 

Hi, I am Humera Firdous of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

CHIEF COMPLAINT:

A 70 year old patient who was a farmer by occupation came to the OPD 3 days ago(i.e. on 24th dec’22)with complaints of breathlessness, fever and dry cough.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 1 week ago.Then he experienced shortness of breath which was associated with fever and dry cough.SOB is insidious in onset, present during rest and is more prevalent during night.SOB is generally experienced after walking a short distance.The patient also complained that the breathlessness is increased by lying down suggesting orthopnea.

Fever accompanied with breathlessness was insidious in onset and was gradually reduced after intake of medicine 3 days ago.

The cough which started around a week ago was insidious in onset and is irresistible.It is non-prdouctive in nature(dry cough).The cough is persistent in nature and is disturbing the patient’s normal sleep.

HISTORY OF PAST ILLNESS:

The patient had history of similar complaints in the past.Since the past 15 years he was experiencing the symptoms of breathlessness and cough occasionally once a year for which he was treated conservatively by  the local RMP.

The patient was diagnosed with Coronary Artery Disease 1 year ago with Left ventricular hypokinesia suggestive of heart failure for which he has been put on conservative therapy. ( The patient was put on statins and fibrinolytics for the same)

The patient was known to be hypertensive since 1 year for which he is on regular medication

The patient had a history of  road traffic accident 2 years ago which lead to a deformity in his spine( Thoracic sclerosis)

PERSONAL HISTORY:

DIET: Mixed

APPETITE : Normal

BOWEL AND BLADDER: Regular

SLEEP: Adequate

ALLERGIC HISTORY: No known allergies

ADDICTIONS:

Alcohol: Occasionally consumed beer with toddy.Stopped 3 years ago

Tobacco:Chronic Cigarette smoker.Started smoking since he was 17 years old.Smokes 2-3 beedis per day.Stopped smoking since he started experiencing SOB

DRUG HISTORY:

Tab.Rovastatin

Tab.Clopidogrel

Tab.Aspirin

Tab.Finofibrate

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

The patient is conscious,coherent and Co-operative

The patient is moderately build and moderately nourished.

No pallor/No cyanosis/No clubbing of fingers/No lymphadenopathy/No icterus/No Oedema of feet

VITALS:

TEMPERATURE:98.7 degree Celsius

PULSE RATE:80  bpm

BLOOD PRESSURE:140/90 mm Hg

SpO2:98%

GRBS:173 mg/dL

SYSTEMIC EXAMINATION:

CVS:S1 S2 Heard,no murmurs 

RESPIRATORY SYSTEM:

No scars are seen on inspection

Shape of the chest:

Tracheal position:Centre

Bilateral Chest Movement 

Tracheal position is confirmed by palpitation

Dyspnea present (CLASS 4 NYHA CLASSIFICATION)

Wheeze present

Breath sounds are Vesicular

CNS:Higher motor functions intact

P/A:Soft,Non tender,BS+

INVESTIGATIONS:

INVESTIGATIONS CHART

DIAGNOSIS:

CHRONIC BRONCHITIS