Case of SOB

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed .


I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

70 yrs old male came to the opd on 7 th sep 2021 with following chief complaints
 •Pain abdomen since 1 week
 •cough since 4 days  
 •Fever since 4 days 
 • Shortness of breath since 1 day 
 
HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 week back then he developed fever which is high grade and associated with chills.
•Pain abdomen (generalized) since 1 week not associated with vomitings and difficulty in passing stools 
•cough since since 4 days associated with expectorantion



PAST HISTORY
•joint pains since 1 year ,not taking any specific medication but use to take pain killer when pain exacerbates 
• Known case of HYPERTENSION  and DIABETES
•History of orthopnea and dribbling of urine present 
• No pedal edema and PND 



 
PERSONAL HISTORY

• Diet - mixed
• Appetite normal
• sleep - adequate
• Bowel movements -regular
• Dribbling of urine
• No allergies 
• Chronic alcoholic and last intake was 15 days back 

FAMILY HISTORY 
                                  Not significant

GENERAL EXAMINATION

  Patient is examined with informed consent
Patient is conscious and coherent but not co-operative , oriented to time, place ,person.
Moderately built and moderately nourished

Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema :  present

VITALS ( At the time of admission)

Temperature- ?
Pulse rate -120
Respiratory rate - 22
Blood pressure- 110/90
Spo2 -97 
GRBS- 208 mg % 

SYSTEMIC EXAMINATION
CVS - S1 S2 HEARD 
RESPIRATORY SYSTEM -  Vesicular breath sounds heard
ABDOMEN - soft ,non tender,non palpable.
CNS - conscious, coherent 

INVESTIGATIONS

CHEST XRAY 

ON 7th  SEP 

CBP 


COMPLETE URINE EXAMINATION :


BLOOD UREA :


LFT :


SERUM CREATININE : 


SERUM ELECTROLYTE:


ON 8 th SEP
SERUM CREATININE

BLOOD UREA 

BLOOD SUGAR -FASTING 

X RAY OF KNEE AND ANKLE JOINT

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