A42 years man presented with shortness of breath

August 27,2022
Case scenario.......

Hi, I am P.sravani , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:A 43 old man presented with shortness of breath, orthopnea, PND and decreased output since one month 





HISTORY OF PRESENT ILLNESS:

Apparently asymptomatic one month ago and developed SOB , orthopnea and decreased urine output 









ASSOCIATED DISEASES:Diabetes mellitus, hypertension 





PAST HISTORY:Post CPR status revived 
K/c/o diabetes mellitus since 10 years
K/c/o HTN since 3 years



PERSONAL HISTORY:
Appetite normal , mixed diet ,bowels regular, mituration normal , no known allergens, no addictions



FAMILY HISTORY:
No prominent history

DRUG HISTORY:Diabetes mellitus 
Hypertension 
CAD



GENERAL EXAMINATION:
>Pallor : Present

>Icterus : Not seen

>Cyanosis : Not seen

>Clubbing : Not seen

>Lymphadenopathy : Not seen


>Edema : B/L Pedal edema seen

(Pic upload)

VITALS:
Temperature: 98.6c/f

Pulse:_88__ beats per minute

Respiratory rate: 14__cycles per minute

Blood pressure: ____110/70 mm of Hg

SPO2: ___98

SYSTEMIC EXAMINATION:

Cardiovascular system:

_no__ thrills
No___murumurs
Cardiac sounds: S1, S2

Respiratory system:

__no__ dyspnea
__no__ wheezing
Breath sounds heard: vesicular

Abdomenshape: scaphoid 


No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious: normal 
Speech: normal______

INVESTIGATIONS:
Biochemical investigations:
   
Pics upload...

PROVISIONAL DIAGNOSE: CKD on MHD

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