General medicine case-8

CASE scenario....

Hi, I am D.Rajashri, 3rd BDS student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

                 CASE HISTORY

Patient details 
A 60 years old male,Daily wage labour,resident of kamagul , presented with
Chief complaint 
*Chest pain since 1 month
*Difficulty in breathing since 1 month
*Cough since 1 month
*Neck pain since 1 month
*Fever since 1 month
History of present illness 
*Patient was apparently asymptomatic 1 month back,than he developed chest pain, left sided radiating to upper limb and back of chest,no relation to food intake.
*Shortness of breath since one month,which was insidious in onset,and gradually progressed from grade 2 to grade 3,no History of orthopnea and PND.SOB aggrevating on talking and eating, relieving on rest.
*Cough-non projectile,productive white,frothy phlegm.no history of seasonal variation 
*Neckpain since one month ,a slight swelling of neck,difficulty and pain in side to side head movements,which was radiating towards shoulder, aggrevating on head movrments, relieving on rest
*Fever since one month,high grade fever associated with chills,no diurnal variation, aggrevating on eating.
History of past illness
*History of similar complaint in the past ,3 months back,which was relieved on medication 
*History of hypertension since 20 years
*No history of Diabetes, Tuberculosis, epilepsy.
Drug history
*Ambroxal hypochloride syrup
*Furosemide 40mg
*Ampimol 650 mg
*Paracetamol 
Family history
No similar complaints in the family 
Personal history
Diet-mixed diet
Appatite-normal
Sleep-adequate
Micturition-occasional burning mirturition
Bowl and bladder- normal
Allergies -no
Addictions-chronic alcoholic and smoker since                      30 years
General examination
Patient was conscious, coherent, cooperative and was well oriented to time and place
Patient was normally built and normally nourished
Pallor-yes
Icterus-no
Cyanosis-no
Clubbing-no
Lymphadenopathy-no
Oedema of foot-no
Vitals
BP-150/110 mg
Systemic examination
Respiratory system:
Chest is symmetrical
Position of trachea-central
Breath sounds-vesicular
Provisional diagnosis
Acute myocardial infarction 
Cardiac arrythmia
Pneumonia 
Heart failure
Agina pectoris
Pneumo thorax 













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