General medicine E-log 3

A 70 YEAR OLD MALE CAME WITH SHORTNESS OF BREATH

Hi,Iam Harichandanarao 3rd sem medical student.Thus is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio.


A  70 year old man shepherd by occupation resident of nalgonda came with the chief complaints of:
Shortness of breath since 20days
Cough since 20 days

HISTORY OF PRESENT ILLNESS:
Patient was normal 20 days back...he noticed shortness of breath while walking and mucoid  cough on and off which is not blood stained
His urine output is normal
Loss of appetite since a month
No case of fever,chest pain,vomitings

HISTORY OF PAST ILLNESS:
He was diagonosed with plueral effusion 10 years ago and then he was normal for 10 years and noticed SOB since 20 days...10 years ago he was an alcoholic after getting diagnosed with plueral effusion he overcame his drinking habit for 7 years and in the last 3 years he again started drinking alcohol he noticed SOB after taking alcohol...and went to local hospital in miryalguda where his x-ray was taken and he came to our hospital for further treatment.
PERSONAL HISTORY:
Appetite is lost
Regular bowels
Normal micturition
No known allergies
Smoked for 40 years stopped 10 years back
PHYSICAL EXAMINATION:
Temperature-98.4°
Bp-130/60
No pallor,cyanosis,icterus,oedema of feet,lymphadenopathy
CARDIAC EXAMINATION:
No thrills,no murmers
S1 and s2 heard
CNS:
Patient is conscious 
Speech is normal
No neck stiffness
INVESTIGATIONS:
TREATMENT:
Inj.augmentin 1.2gm/iv/tid
Inj.pan 40mg iv/od
Tab.mucinac ab/tid
Tab.pcm 650mg po/ sos
Syrup.ascoril 2ml po/tid
Monitoring vitals
12/6/22:
13/6/22:
14/6/22:8am
6:50pm
15/6/22:8am
84 pulse rate11:45am











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