68M WITH PYREXIA and COPD

 28 October 2023

Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio.

Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current based evidence based inputs.

CHIEF COMPLAINTS-

A 68yr old male patient who is farmer by occupation resident of Tangedpalli came with the chief complaints of-

-fever since 2 days

-difficulty in breathing since 1 day

-facial puffiness since 2 days 

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 2 days back.Then he developed fever which was low grade,intermittent in nature ,relieved on medications associated with chills and rigor,  facial puffiness,generalised body pains.No diurnal variations.

H/o shortness of breath since 1 day which was sudden in onset, grade 3 .It was not associated with chest pain,palpitations,pedal edema and decreased urine output.

H/o facial puffiness 

No C/o cough,cold ,burning micturition, vomiting, loose stools,pain abdomen.

PAST HISTORY-

K//C/O HTN since 1 year on medications-Tab Amlo 5mg+Atenolol 50 mg.

N/K/C/O DM ,EPILEPSY, ASTHMA, TB.

No h/o blood transfusion. 

PERSONAL HISTORY-

Married 

Occupation-Farmer

Appetite-Normal

Diet-mixed 

Bowels-regular 

Micturition-normal

Alcohol-occasional,monthly once

Tobacco-smoking ,daily 10 beedis,stopped 15 days back

FAMILY HISTORY-

No significant family history found.

GENERAL EXAMINATION-

Patient is conscious, coherent and cooperative. 

Patient is moderately built and well nourished. 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers 

No lymphadenopathy 

No pedal edema 

VITALS-

Temperature-afebrile

Pulse rate-60bpm

BP-150/90mmHg

RR--22cpm

GRBS-116 mg%

SPO2 at room air-74%


SYSTEMIC EXAMINATION-

CVS-

S1S2+,no murmurs,thrills absent

P/A-

Non tender,soft,bowel sounds heard

CNS-

Conscious

Normal speech

No neck stiffness 

Sensory-normal 

Motor-normal

Cranial nerves-normal

No signs of meningeal irritation

RESPIRATORY SYSTEM-

Inspection-

Upper respiratory tract -oral cavity,nose and orpharynx normal.

Chest appears bilaterally symmetrical .

Shape of chest-barrel shaped

Trachea position central

Skin over chest is normal

No sinuses, no scars

Palpation-

No rise of local temperature 

No tenderness 

All the inspectory findings are confirmed

Expansion-symmetrical

Trachea in central position. 

Percussion-Resonant 

Auscultation-

Supraclavicular-(NVBS)(NVBS)

Infraclavicular-(NVBS)(NVBS)

Inframammary-(crepts )(NVBS)

Supramammary-(NVBS)(NVBS)

Axillary-(NVBS)(NVBS)

Infraaxillary-(NVBS)(NVBS)

Suprascapular-(NVBS)(NVBS)

Interscapular-(NVBS)

Subscapular -B/L crepts heard

TREATMENT-

Inj. AUGMENTIN

Inj. PAN

Inj. NEOMOL

O2 supplementation













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