A 65 year old male with abdominal distension, shortness of breath and pedal edema
September 27,2022
Hi,I am Athram Divya Sri 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. CASE SHEEET
CHEIF COMPLAINTS:
A 65 year old male patient resident of buvnagiri came to OPD with chief complaints of
Abdominal distension since 15 days
Shortness of breath since 15 days
Pedal edema (pitting type) since 6months
6 episodes of loose stools since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 months back then he developed pedal edema(pitting type) which is relieved on elevation patient then developed shortness of breath since 1 month
After 15 days patient started developing abdominal distension
HISTORY OF PAST ILLNESS:
diabetes since 1 year
hypertension since 1 year
No CAD
No asthma
No tuberculosis
PERSONAL HISTORY:
Married
Appetite - normal
Diet - mixed
Bowl movement - regular
Micturition - normal
Sleep- normal
Addiction: regular
FAMILY HISTORY:
No significant family history
DRUG HISTORY:
No significant drug history
PHYSICAL EXAMINATION:
General examination:
Patient was conscious, coherent
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema (pitting type)
Vitals:
Temperature : Afebrile
Pulse rate : 102 /min
Respiratory rate : 18 per minute
Blood pressure : 110/80 mm of Hg
sPO2 : 98%
GRBS-126mg%
Systemic Examination :
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
no dyspnea
No wheezing
central trachea
vesicular breath sounds
Abdomen
Distended shaped abdomen
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
INVESTIGATIONS:
ECG
ultrasound
