GENERAL MEDICINE E-log-1

A 80 years old female came with shortness of breath and dry cough for the past 3 days.

Hi,I am Tharun 3rd sem medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio         

Cheif complaints : shortness of breath and dry cough for the past 3 days.

HOPI: 80 years old female came to causality with complaint of shortness of breath and dry cough for the past 3 days, patient was apparently alright 3 days back then she developed shiverness of breath which was insidious in onset and gradually increased and progressive and increased on exertion.

PAST HISTORY:

20 years back she had complaints of giddiness and headache for which she went to hospital and eventually diagnosised with hypertension for which she was prescribed with atenolol+amlodipine

6 years back she had complaints of polyuria she went to hospital and diagnosied with Diabetes Mellitus type-ll and she was persisted metformin 500mg

3 years back she had complaints of abdomen pain in iliac fossa for which she was admitted in hospital and diagnosised to have appendicitis and has undergone appendectomy

2 years back she had similar complaints of shortness of breath mild B/L pedal edema for which she was diagnosed with B/L preural effusion, left lower rib collapse and pulmonary edema and her 2D echo finding showed dilated right and left atria,concortric LVH , moderate PAH and diastole dysfunction.

1 year back also she had complaints of shortness of breath which was diagnosed as pleural effusion and was given conservative prescription

DRUG HISTORY:                                                        atenolol+Amlodipine for hypertension.          Metformin 500mg for diabetics mellitus.        

GENERAL EXAMINATION:

Pallor - present

Cyanosis - no

Icterus - no 

Temp : 98.6F

Pulse rate : 42/min.      

SPO2 at room air 96% at RA litres of O2. 

GRBS - 127mg%


SYSTEMIC EXAMINATION :

CARDIO VASCULAR SYSTEM:.                               Cardiac sounds  S1 , S2 

RESPIRATORY SYSTEM:

Dyspnoea: yes 

Breath sounds - vesicular

ABDOMEN:

No tenderness

No palpable mass

Spleen - not palpable

Bowel sounds - yes

CNS:

Conscious 

Speech - normal 

PROVISIONAL DIAGNOSIS :

Heart failure

Cardiogenic pulmonary edema 

INVESTIGATIONS:

ECG 

















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