CASE OF SOB and DECREASE URINE Output



 March 04, 2022

B.Aishwarya Laxmi 

Roll no: 152

This is an online E-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section.

67 yr old male came to OPD with 
Chief complaints : sob,cough, generalized weakness from 1month
Decreased urine output and pedal edema from 1 week
HOPI : pt apparently asymptomatic 1 month back then he developed sob which increased on lying down , exertion and decreased on sitting posture and rest and he has wheeze
No history of orthopnea, chest pain, PND

Cough from 1month associated with expectoration it is mucoid non foul smelling non blood stained 
He has pedal edema and decreased urine output from 1 week
Past history : similar complaints 2 years ago
Not k/c/o htn,dm,cad,tb,asthma
Personal history: 
Diet - mixed
Appetite - decreased
Bowel and bladder - regular
Habits- occasional alcoholic
             Tobacco chewing and will smoke 20 beedis                  per day
Sleep - adequate
General examination conscious , coherent , cooperative
No pallor
      Icterus
      Cyanosis
       Clubing
       Lymphadenopathy
Vitals
         BP 120/70mmhg
         PR 79 BPM
         RR 20
         Spo2 95 
Systemic examination
       Respiratory examination
        BAE +ve and normal vesicular breath sound                 heard 
        B/L crepts IN ISA
        CVS 
        S1S2 heard 
        No murmurs  heard
        Abdomen
        Soft non tender
        No hepatomegaly and splenomegaly
        CNS :. Higher motor and sensory functions are           normal 
   Investigations
         Usg





Provisional diagnosis
    Acute exacerbated COPD with type 2 respiratory 
  Failure with severe PAH.



Comments

Post a Comment

Popular posts from this blog

Online blended bimonthly assignment toward summative assessment for the month of May 2021

Image
GENERAL MEDICINE case study of may NAME: B.AISHWARYALAXMI  ROLL NO: 152 SEMESTER: 8th    I have been given the following cases to solve in an attmept to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and coem up with a treatment plan. This is the link of the questions asked regarding the cases: medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  1)PULMONOLOGY First case :      A 55 Year Old Female with Shortness of Breath, pedal Edema and Facial puffiness. https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html QUESTIONS : 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localiza...
Read more

Final examination long case

Image
  I This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 1701006018 30year old female with facial puffiness and pedal edema. A 30 year old female patient who is house wife by occupation resident of Nalgonda came to OPD with chief complaints of     Abdominal pain since 2days  Facial puffiness and pedal Edema since 2 days  Shortness of breath since 2 days  History of presenting illness : Patient was asymptomatic 7 months back She developed facial puffiness and bilateral leg swelling which was pitting in type  SOB: ...
Read more