second internal practical exam : case of 65 year old male with Sob and stomach pain
5/12/22:
CHIEF COMPLAINTS:-
Pain in the lower abdomen for 5 days
Shortness of breath for 5 days
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic 25 years back then he had a cough that was blood-stained when he was diagnosed with Tuberculosis and was on ATT for 6 months after he was said that he is free from the disease.
Then
2 years back then he started having shortness of breath Grade 2 ( sob on some physical activity) which is insidious in onset and relieved temporarily on medication, from then he had intermittent shortness of breath which relieved on the medication temporarily.
6 months back he again developed shortness of breath of grade 2 ( walking after 300 m ) which is insidious in onset where he was taken to a higher center where he was prescribed a medication that he didn’t use properly and used only on the aggravation of shortness of breath.
After that 5 months back he suffered from an accident where his left tibia and left rib got fractured where he was managed with POP casting for 45 days and on calcium tablets ( dose -500mg).
9 days back He also experienced diffuse pain all over the abdomen which was insidious in onset and was not radiating and relieved on temporary medication .
But pain abdomen was resolved 2 days ago
NO H/O of Hematemesis, Malena, Vomiting, Nausea H/O bulky stools, black tarry, and clay-coloured. H/O Jaundice, pruritus
NO H/O fever with chills
NO H/O anorexia
NO H/O orthopnea, palpitations
NO H/O frothy urine
NO H/O haematuria, oliguria
NO H/O blood transfusions
NO H/O tattoo marking
NO H/O loss of weight
He also developed shortness of breath since 5 days which was insidious in onset grade 3 ( sob on normal physical activity) which was relieved on medication ( drug unknown; dose - unknown)
There is a history of cough which is productive ( which has mucous as content scanty in quantity; white in colour; and no foreign bodies)
fatigue; sweating ;
No history of palpitations
No H/O fever, or joint pains.
PAST HISTORY:-
History of pulmonary TB 25 yrs back
No history of DM
No history of Hypertension, asthma, epilepsy, TB
No history of prolonged hospital stay
No history of previous surgeries
PERSONAL HISTORY:-
Appetite - Reduced since 1 year
Diet - Mixed
Bowel and Bladder - Regular
Sleep - inadequate
Addictions - stopped 20 years back, before alcohol and smoking but was a chronic smoker in the past
FAMILY HISTORY:-
None of the patient’s parents, siblings, or first-degree relatives have or have had similar complaints or any significant co-morbidities.
ALLERGIC HISTORY:-No allergies to any kind of food or medication.
Asthma/COPD/ CAD/ Blood transfusions
Any surgeries, drug usage, allergies.
HIGH ARCHED PALATE
GENERAL EXAMINATION:-
A 65 old male patient, supine decubitus who Is conscious, coherent and cooperative
comfortably seated/lying on the bed, well-oriented to time,
place and person
There is Pallor
No, Icterus, cyanosis, clubbing
generalized lymphadenopathy and no pedal edema
Pulse: Rate, rhythm(regular)character(normal ), volume :- low
peripheral pulsations [Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis]- present
no radio radial delay
BP: 120/80 mm Hg measured on Rt Upper arm In supine position
Respiratory Rate:25 CPM; type- Abdomino thoracic
The above-mentioned positive history is in favor of respiratory; GIT and CVS hence I have examined all the systems.
First I examined respiratory system;
RESPIRATORY SYSTEM:-
INSPECTION:
1. Shape of Chest - normal
2. Trachea position central
3. Apical Impulse - no visible
4. Movements of the chest: Respiratory rate:- 14cpm Type- abdomino thoracic type no accessory muscles involved.
5. Skin over the chest: Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.
6. All the areas appear normal.
PALPITATION:
1. No local rise in Temperature and tenderness
2. All inspector findings confirmed. (Tracheal position, apex beat)
3. Expansion of the chest- equal in all planes
PERCUSSION:
Resonant all over the chest
AUSCULTATION:
1. Normal breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.
:-
PER ABDOMEN:
INSPECTION:
9 REGIONS
Shape (scaphoid)
No Distention of Abdomen
Flanks- full
Umbilicus- normal
The skin over the abdomen: (smooth)
No engorged veins, visible pulsations, or hernia orifices.
PALPATION:-
Tender in the following areas.
No hepatomegaly and splenomegaly
PERCUSSION:
Normal
AUSCULTATION:
1. Bowel Sounds - heard
CVS:-
INSPECTION:-
Appears normal in shape
Apex beat is not visible
PALPITATION:
1- All inspector findings were confirmed.
2-Trachea is central.
3-Apex Beat - diffuse
No palpable murmurs (thrills)
AUSCULTATION:-
S 1; S 2 heard in all the areas
INVESTIGATIONS:-
29-11-2022
30/12/22:
