A 40 YEAR OLD WITH CHEST DISCOMFORT AND SOB

-

 

VIJAYA RATNA  34


A 40-year-old male tea seller by occupation resident of Suryapet came to casualty with chief complaints of   

    Shortness of Breath on exertion since 2 months 

    Chest Discomfort since 2 months

 

HISTORY OF PRESENT ILLNESS

 

            The patient was apparently normal 2 months back.His daily routine starts usually by eating,sleeping,consuming 90 ml of whisky,smoking,taking rest and going to his tea stall in the evening works overnight near the Highway.

He spent in the rain one night following the next day he developed fever,mild cough with cold.He used T.Dolo 650 mg but didn’t subside.So he visited a nearby hospital,diagnosed with COVID – 19 and joined there.Since then,Patient had Shortness of Breath Grade II which got progressed to SOB Gr III in few days. Later,he was diagnosed with Hypertension.

 

PAST HISTORY

Denovo Hypertension since 2 months

H/o COVID - 19 [1 month back]

Not a known case of DM,Asthma,TB,Epilepsy

 

PERSONAL HISTORY

Appetite - normal

Mixed diet

Bowels - Regular

Micturition - Normal

Chronic Alcoholic [90 ml daily]

Chronic Smoker [4-5 beedis/day]

 

TREATMENT HISTORY

No specific treatment history

 

FAMILY HISTORY

His mother is a known case of Hypertension

 

GENERAL EXAMINATION

            Patient was conscious,coherent,cooperative and examined in a well lit room


VITALS

Temperature - Afebrile

Pulse rate - 90 bpm

Respiratory rate - 20 cpm

BP - 180/100 mmHg

SpO2 - 98% at room air

 

PHYSICAL EXAMINATION

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing of fingers/toes - absent

Lymphadenopathy - absent

Malnutrition -  absent

dehydration – absent

 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

  • S1 and S2 heard
  • No thrills
  • No murmurs
RESPIRATORY SYSTEM
  • Dyspnea present
PER ABDOMEN
  • Obese shaped abdomen
  • No tenderness
  • No palpable mass
  • No hernial orifices
  • No free fluid
  • No bruits
  • Liver and spleen are not palpable
  • Bowels sounds  heard

 CNS

  • NAD

 

INVESTIGATIONS

ULTRASOUND



ECG


2D ECHO


X RAY



22/02

COMPLETE BLOOD PICTURE

 Haemoglobin – 15.8 gm/dl

Total Leucocyte Count – 8400 cells/cu.mm

Platelet count – 3.11 Lakhs/cu.mm

COMPLETE URINE EXAMINATION – Normal

BLOOD UREA – 29mg/dl

SERUM CREATININE – 0.9mg/dl

SERUM ELECTROLYTES

Sodium – 142 mEq/L

Potassium – 4 mEq/L

Chloride – 102 mEq/L

 LIVER FUNCTION TEST

Total Bilirubin – 0.86 mg/dl

Direct Bilirubin – 0.24 mg/dl

SGOT[AST] – 44 IU/L

SGPT [ALT] – 65 IU/L

Alkaline Phosphate – 212 IU/L

Albumin – 4.5gm/dl

RANDOM BLOOD SUGAR – 93mg/dl

 

PROVISIONAL DIAGNOSIS

Uncontrolled Hypertension,Heart Failure with preserved ejection Fraction

Grade I HTN Retinopathy changes

 TREATMENT

T.Nicardia 10 mg /PO/TID

T.Telma 40mg/PO/OD

Tab.pantop 40mg

Syp.Sucralfate 15ml

BP Charting

 

 

 

 

 

 

 

 

 

 

 

       

 


Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE ASSIGNMENT [JUNE 2021]

-
Name - D.Vijaya ratna , MBBS[3rd sem] Roll number - 34 QUESTION 1:   Competency tested for Peer to peer review and assessment :  Please go through one particular answer of ten students in this link: https:// generalmedicinedepartment. blogspot.com/2021/06/ bimonthly-formative-and- summative_19.html?m=1 and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.              PULMONOLOGY REVIEW-  https://aitharaveena.blogspot.com/ CASE -   https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html This is the case of COPD presenting with the chief complaints of shortness of breath,generalized weakness,pedal edema,facial puffiness.She has been diagnosed with diabetes[8 years ago] and hypertension[5 years ago].The evolution of symptoms are explained well in chronological order.Placebo effect was explained well . All the answers are simple and easy to understa
Read more

A 54 year old Female with SOB

-
Image
Hi, This is Vijaya Ratna,5th sem medical student.This Elog depicts the patient centered approach to learning. This is an online eLogbook recorded to discuss and comprehend our patient's deidentified health data shared, after taking his/her/guardian's signed informed consent. **This is an ongoing case.I am in the process of updating and editing this Elog as and when required** Date of admission : 1/08/2022 A 54yrs old female resident of Nalgonda,occupation by housewife came to OPD with chief complaints of SOB since 2days and generalised weakness. PRESENT ILLNESS Patient was apparently asymptomatic 8 months ago then she developed SOB which was insidious in onset and continuous in nature which aggravates on walking and on lying down.It gets relieved on sitting position [grade 3 SOB].It is also associated with dry cough.She also has genearalised weakness and also fever since 8months which is intermittent in nature. She consulted a local doctor in Nalgonda from where she got to kno
Read more

A 60 YEAR OLD MALE WITH LOSS OF APPETITE AND PEDAL EDEMA

-
Image
VIJAYA RATNA DANDE 34   Hi,I am Vijaya ratna 3rd sem Medical student.This is an online elog book to discuss our patient's health data shared after taking his/her/guardian's consent.This also reflects patient centered care and online learning portfolio.This E-log book reflects my patient- centered online learning portfolio. Under the guidance of Dr.Durga Krishna Sir[PG] A 60 year old male farmer by occupation resident of nalgonda came to casualty with chief complaints of Loss of appetite since 2 months Pedal edema since 1 month HISTORY OF PRESENT ILLNESS     The   patient was apparently asymptomatic 2 years back,during this time his nephew got expired and patient started developing anxiety issues and used to take alcohol daily [previously occasional drinker] and after 15 days of expiry of his nephew patient started developing fever, sudden onset,high grade associated with generalized body pains and during this time, patient was diagnosed with hypertension. Patient used medicatio
Read more