A 51 year old male patient came to the OPD with chief complaints of shortness of breath since 2 months

 Hi, I am greeshmaA, 6th  Sem Medical Student.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. 

CHIEF COMPLAINTS 

51M farmer by occupation , resident of nalgonda ,came to opd with c/o shortness of breath since 2 months

HOPI 

Patient was apparently asymptomatic 2 months ago then he developed SOB of insidious onset, gradually progressive increasing in intensity since 2 months (Glade II- III)

No h/o constipation , nausea , vomiting ,burning micturation 

PAST HISTORY :

N/k/c/o DM , HTN , CAD,TB, epilepsy , thyroid disorders 

FAMILY HISTORY : 

not significant 

PERSONAL HISTORY : 

Decreased apetite 

Mixed diet 

Decreased bowel movements 

Normal micturation 

No known allergies 

Alcoholic since 3 yrs 

GENERAL EXAMINATION :

I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time, place and person

- well built and adequately nourished

- pallor present 

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- pitting type pedal

VITALS :

Temperature :  afebrile

BP :  100/70 mmhg                       

Pulse rate : 100/min

Respiratory rate : 16/min

SPO2 : 98% RA

SYSTEMIC EXAMINATION :

CVS : 

S1S2 +

Cardiac murmurs heard

No thrills

RS : 

Position of Trachea - central

BAE +

NVBS +

P/A :

Soft , Non tender

CNS :

NFND

PROVISIONAL DIAGNOSIS: anemia secondary to blood loss