General Medicine - 13

A 57 YEAR OLD MALE CAME WITH SHORTNESS OF BREATH AND CHEST PAIN.

Hi, I am Dussa Sri Snehitha, 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 57 year old male, hailing from aakaram, came with chief complaints of: 
- Shortness of breath since morning
- chest pain since morning

History of present illness:

The patient was apparently asymptomatic 3 months back. He then developed Shortness of breath and was admitted in our hospital, after investigations, was diagnosed with edematous pyelonephritis and underwent 3 sessions of hemodialysis.

Then 1 day back, he developed shortness of breath in the sleep, associated with chest pain, at morning 3 am, for which he was bought to our hospital.

Past history:

- 3 months back, was diagnosed with edematous pyelonephritis
- hemodialysis 3 sessions done
- known case of Diabetes mellitus and hypertension since 8 years and was on regular medication.

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: normal
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

No pallor 
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
pedal edema present

VITALS:

Temperature: 97.4 F

Pulse: 111 beats per minute

Respiratory rate: 34 cycles per minute

Blood pressure: 160/100 mm of Hg

SPO2: 67%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard

Respiratory system:

dyspnea present
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape of abdomen: scaphoid
No tenderness
No Palpable mass
Non palpable liver
No Palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

Investigations:
PROVISIONAL DIAGNOSIS:
Myocardial infarction



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