A 70 year old patient with shortness of breath and pedal edema

September 12,2022


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 SHEET

CHIEF COMPLAINTS:

A 70 year old patient farmer by occupation resident of  vutlapalli, Nalgonda came to the OPD with chief complaints of
shortness of breath since 1 month( gradeIV)
pedal edema since 5 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month back .He developed shortness of breath 1 month back and associated with facial puffness and pedal edema for which he was taken to a private hospital at Halya and was investigated and his himoglobin was found to be 3.9gm% and was transfused 2 units and was discharged and came to home.Patient again developed pedal edema and shortness of breath from 5 days.

PAST HISTORY:

 Patient is not a K/C/O DM ,Asthma , CAD, epilepsy 

PERSONAL HISTORY:

Married
Appetite - normal
Diet - mixed
Bowl movement - regular
Micturition - normal
Sleep- normal
Addiction: regularly 

FAMILY HISTORY:

Not significant family history

ALLERGIES: 

No allergy

DRUG HISTORY: 

No drug history

PHYSICAL EXAMINATION:

General examination:

Patient is conscious coherent cooperative

Pallor present
 no icterus 
no cyanosis
edema - bilateral pedal edema
               Pitting type
no lymphadenopathy
No clubbing

Vitals:

Temperature : 98.6°F
Pulse rate : 102 /min
Respiratory rate : 16 per minute 
Blood pressure : 110/70 mm of Hg
sPO2 : 95 % 
GRBS-102mg% 

INVESTIGATIONS:

Popular posts from this blog

A 65 year old male with abdominal pain neck pain and neck stiffness

Image
July 24,2023 Hi,I am Athram Divya Sri 5th 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 SHEET CHIEF COMPLAINTS: A 65year old male patient resident of nalgonda farmer by occupation came to OPD with chief complaints of Abdominal pain since 1 year  Lower back pain radiating to lower limbs Neck pain and stiffness since 1year HOPI: Patient was apparently asymptomatic 4 year. 4years ago patient has H/O trauma (he had fall while taking his cattle to the field) of right hip and hemianthroplasty was done.  then he  started  having neck pain since 1yr and  radiation to bilateral upper limb which is insidious in onset gradually progressed to current.  Difficulty in flexion and extension of neck and tingling sensation of bilateral upper limb Patient grad...
Read more

A 40 year old male with abdominal pain

Image
July 31,2023 Hi,I am Athram Divya Sri 5th 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 SHEET CHIEF COMPLAINTS: c/o  Abdomen pain  since 4 days  HOPI: Patient was apparently asymptomatic 4 days back then developed pain over the left hypochondriac region since 4 days radiating to the right hypochondriac region  C/o vomiting since 4days ,3 episodes watery in consistency ,non-blood stained,non foul smelling No c/o fever , decreased urine output ,loose stools H/o Burning micturition since 2 days  C/o SOB , palpitations, orthopnea,pnd  PAST HISTORY: Not a known case of HTN,DM,Asthma,Epilepsy. PERSONAL HISTORY:  Diet - Mixed Appatite - Normal Sleep - Normal Bowel and Bladder -Regular. Allergy - None Addictions -Alcohol addiction since 10 years last c...
Read more

A 41 year old female with diabetes, abdominal pain ,nausea and vomiting

Image
July 29,2023 Hi,I am Athram Divya Sri 5th 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 SHEET CHIEF COMPLAINTS:  A 41 year old female housewife  from Miriyalguda came to casualty with C/O: Nausea and vomiting since 3days Abdominal pain since 3days HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 4days back then she developed nausea and vomiting, 8-10 episodes of vomiting, content food material watery, non bilious, non projectile, not blood binged and associated with Abdominal pain of diffuse type and non radiating. No H/O chest pain, Pedal edema, burning micturition, coughing, palpitations, excessive sweating, giddiness and wheeze H/o skipping OHAs since 2 days HISTORY OF PAST ILLNESS: K/c/o Diabetes Mellitus type 2 since 2 years for which she is on med...
Read more