61 Y/O Male with shortness of breath

This is srujana from eight semester.  This is an elog depicting  patients deidentified data centered approach for learning medicine.ll This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them


Cheif complaints -
Patient complains of shortness of breath since 1 yr
Abdominal distension since 1 yr

History of present illness:

 

The patient is apparently asymptomatic one year ago  then he developed shortness of breath and abdominal distension

    •shortness of breath-insidious onset , grade-3 (NYHA) , gradually progressive not relieved on taking rest and aggravated on walking
  • History of left anterior septal deviation 
  • History of abdominal distension -insidious onset not associated with pain ,tenderness 
  • No history of loose stools and vomiting
  • No History of orthopnea, PND and cough and palpations
  • No history of chest pain , upper respiratory tract infection 

Past history -
No a k/c/o HTN/DM/TB/Epilepsy
K/c/o CVA -1 yr ago
K/c/o rt.hydrouteronephrosis -2 months back
 
Surgical history -
Lithotripsy and dj stent -1 and half month ago

Allergy history - 
No known allergies

Personal history -
Diet -mixed
Appetite -normal 
Bowels -regular
Micturition -normal
Occasional drinker 1 yr ago


Family history -
Not significant

GENERAL EXAMINATION:


•Patient is consious, coherent ,cooperative
•moderately built and nourished
•pallor -present (mild)
•no icterus,cyanosis,clubbing,lymphadenopathy,edema


Vitals-

Temperature -afebrile
Pulse rate -80bpm
Respiratory rate -12cpm
Bp-110/80 mmhg


SYSTEMIC EXAMINATION-
CVS: S1, S2 heard
          no thrills
          no murmurs
RESPIRATORY SYSTEM:
          Dyspnoea +
           Crepts  + @rt 
           BAE +
          Trachea slightly shifted to right side
          Breath sounds heard
ABDOMEN:
          Shape of abdomen: scaphoid
          No tenderness 
          No palpable masses 
          No free fluid 
          no bruits 
          no organomegaly
          normal hernial orifices
          bowel sounds+
CNS: C/C/C to time, place, person
          No signs of meningeal irritation 
          no focal neural deficit found
          normal speech
          functions of cranial nerves, motor & sensory system are normal

Reflexes:  
       biceps triceps supinator knee ankle
right ++       ++          +             ++         ++
left   ++        ++          +             ++         ++

plantar- flexor



Local examination -respiratory system

Inspection -
Nose -left anterior septum deviation
Mouth and nasopharynx -ve
Chest symmetrical shape normal
Trachea position central
Drooping of shoulder ve
Retractions,indrawings -ve
No scar or sinuses or engorged vessels
Movements with respiration +ve

Palpation-
Trachea midline
Movement with chest expansion seen
Resonant sound in all areas present

Ascultation
BAE+

Abdomen examination -
Inspection no visible scars sinuses and engorged vessels
Shape distented flanks full
Umbilicus everted

Palpation-
No raise in temperature no tenderness no abnormal findings

Percussion fluid thrill -ve
Spleen and liver non palpable


Ascultation
Bowel sounds heard
No bruit



Investigations -




Provisional diagnosis -
SOB -under evaluation 



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