GM Short Case
Final Examination Practical Short Case
This is an online E-log book to discuss our patients de-identified health data shared after taking his /her/ guardian informed consent here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
Date of admission:- 5/2/22
A 67year old male has come to casualty with chief complaints of acute onset of shortness of breath since 1 week , swelling in leg since 1 day, SOB while lying down and also sudden SOB during sleep.
History of Present illness:-
Patient was apparently asymptomatic since 20 yrs back then he developed severe cough with sputum went to hospital and diagnosed with TB use ATT course for 9 months and relieved.
Patient developed shortness of breath of grade 2-3, grade 2 pedal edema of pitting type.
Past History:-
know case of TB. Not a know case of diabetes, hypertension, asthma, epilepsy.
Personal History:-
Patient has mixed diet.
Sleep is inadequate.
Appetite is decreased.
Bowel and bladder movements are regular.
Chronic alcoholic since 50yrs (3times a week 180-360 ml).
Chronic smoker since 50 yrs (18 beedis/day).
Family History:-
No members in family has similar complaints.
Drug history:-
No allergie to know drugs.
General examination:-
Patient is conscious, coherent, cooperative and well oriented to place and time.
No anemia ,no pallor, no cyanosis, no icterus , no generalised lymphadenopathy.
Clubbing is seen.
Vitals:-
Temperature: afebrile ,Pulse rate: 98 beats per minute, BP: 110/80 mm Hg, Respiratory rate: 26 cycles per minute, SPO2:83, GRBS :111mg/dl
Systemic Examination:-
CVS: S1 and S2 heard ,bilaterally symmetrical chest wall, no thrills and murmurs heard.
Respiratory system: bilateral air entry present, wheezing present, position of trachea central.
CNS: patient is conscious and coherent.
Abdomen: distended.
Investigations:-
Comments
Post a Comment