A 73 year old male came to casuality with shortness of breathe
Hi I am, A satyanarayana (roll no:12), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.
A 73 yr old male patient who is a farmer by occupation came to casualty with shortness of breath
Case sheet:
Chief complaints:
The patient complained of severe breathlessness since 10days and epigastric pain since 4days
History of present illness
The patient was apparently asymptomatic 12yrs back.Then he developed chronic cough for which he went to a hospital where he was diagnosed with Tuberculosis then he used medication for 6months Then 4yrs back the patient developed a swelling in the scrotum which was diagnosed as hydrocele and then the surgery was done.Since 2months the patient is having breathlessness and used medicines given by the local doctor.He used to drink alcohol to get sleep at night.
1day back he developed a grade 5 SOB then he was brought to the hospital
History of past illness:
The patient is not a known case of diabetes,asthma,epilepsy and hypertension
Personal history:
Diet- mixed
Appetite- decreased
Sleep- decreased
Bowel Movement’s - irregular
Addictions: cigarette(stopped 12 yrs back) and . alcohol.
No burning micturition
Family history :
No significant family history
Treatment history:
No Diabetes
No HTN
No asthma
No Blood transfusions
Hydrocele surgery has done
Tuberculosis is present 3 years back
General examination;
Patient was conscious, coherent and cooperative
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No generalised lymphadenopathy
No Pedal oedema
Investigations
Serum electrolytes reports
Serum creatinine Report
CLINICAL PICTURES
TREATMENT:
Neb. C duolin and Budecort
Inj Lasix 40 mg
Inj Hydrocort 100 mg IV
Tab ecosprin 75 mg
Tab clopidogrel 75 mg
Tab atorrel
PROVISIONAL DIAGNOSIS
The patient is affected with Relapse pulmonary tuberculosis
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