General medicine case discussion

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

A 60 year old female came to general medicine opd with chief complaints of short of breath since 2 years.

 HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 3 days back. Later she developed shortness of breath  which is insidious in onset even when she is on home oxygenation  with nasal prongs 5 lit/ min since 2 years.
SOB associated with cough along with mucus and wheeze.
No orthopnea, PND .
No chest pain, chest tightness,no fever.

PAST HISTORY -
Patient got infected with tuberculosis 30 years back.
2years ago patient developed shortness of breath with seasonal variation.
Known case of hypertension since 2 years.
18 months ago she consulted psychiatrist 
because of having suicidal thoughts and was diagnosed with schizophrenia.
One year back she was taken to hospital due to continuous episodes of vomiting, then diagnosed with electrolyte imbalance.
Not a known case of Diabetes.
No epilepsy,CAD, syphilis,asthma.

No surgical history 
FAMILY HISTORY -
No significant family history.

PERSONAL HISTORY -
Diet-mixed
Appetite- normal 
Bladder and bowel movements - regular
Sleep- adequate 
No addictions
ALLERGIC HISTORY - no known allergies

DRUG HISTORY -
On medication for TB 30 years ago for 6 months.
Patient is on regular medication for hypertension since 2 years.
Patient is on regular medication with OLANZEPINE and DICORATE for schizophrenia since 18 months.

PHYSICAL EXAMINATION -
GEBERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built,nourished 
No pallor 
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
Pedal edema - absent.

VITAL SIGNS-
Temperature: 96.4F
Pulse:118bpm
BP: 90/60mm of hg 
Respiratory rate: 40cpm
SpO2: 74%, with oxygen prongs 6lit/min-94%
GRBS: 128mg%

SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds
Shape of chest- eplliptical 
No drooping of shoulder 

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

PROVISIONAL DIAGNOSIS
Acute exacerbations COPD with bilateral lower lobe fibrosis (post TB) with hypertension with schizophrenia.

INVESTIGATIONS DONE-
2D echo, ultrasound, bacterial culture and sensitivity, LFT,RFT,blood urea, serum electrolytes

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