A 70 year old male patient came to opd with complaint of shortness of breath , dry cough and fever

Hi i am sarvadnya Mane 3rd sem This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs

Chief complaint - 
70 year old male patient farmer by occupation came to medicine opd with complaint of shortness of breath (SOB), dry cough, fever

History of present illness-
Patient was asymptomatic 1 week ago then he developed SOB with cough and fever.
SOB is present in rest and more in night
He also experienced SOB by walking short distance but he gets releif on sitting.
He developed cough 1 week ago
Cough is non productive (dry cough) which is disturbing patients sleep.
Fever is also present along with SOB
from 3-4 days .

history of past illness- 

The patient had history of similar complaints since past 15 years ,he was experiencing the symptoms of breathlessness and cough and getting treatment from local RMP.           

He was diagnosed by heart failure 1 yr back and and taking medication for it.

He was having HTN since 1 yr and having regular medication.

The patient had a history of road traffic accident 2 years ago which lead to a deformity in his spin injury 
personal history-
DIET: Mixed
APPETITE : Normal
BOWEL AND BLADDER: Regular
SLEEP: Adequate
ALLERGIC HISTORY: No known allergies

Alcohol: Occasionally consumed beer with toddy.Stopped 3 years ago

Tobacco:Chronic Cigarette smoker.Started smoking since he was 17 years old.Smokes 2-3 beedis per day.Stopped smoking since he started experiencing SOB

Drung history -

Tab.Rovastatin
Tab.Clopidogrel
Tab.Aspirin
Tab.Finofibrate

family history-

No significant family history.

general examination-
Conscious and cooperative 
Coherent
Moderately build
No pallor
No icterus
No cyanosis
No lymphadenopathy 
No Pedal edema

Vitals-

TEMPERATURE:Febrile(100 degree Fahrenheit)

PULSE RATE:88 bpm

BLOOD PRESSURE:110/70 mm Hg

SpO2:98%

GRBS:101mg/dL

Systemic examination -

CVS:S1 S2 Heard,no murmurs 

respiratory system-

No scars are seen on inspection

Shape of the chest:

Tracheal position:Centre

Bilateral Chest Movement 

Tracheal position is confirmed by palpitation

Dyspnea present.

Wheeze present.

Breath sounds are Vesicular

CNS:Higher motor functions intact

P/A:Soft,Non tender,BS+
 
    
Clinical Diagnosis-
Chronic bronchitis

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