A 61 y/o male with shortness of breath

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E-LOG GENERAL MEDICINE

Hi, This is Siddhartha , an eighth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

Chief complaints: 
 
Patient complains of shortness of breath, Abdominal distension.
  • Shortness of breath since 1 year
  • Abdominal distension since 1 year
History of present illness:

The patient is apparently asymptomatic one year ago , then he developed shortness of breath and abdominal distension.

  • shortness of breath: insidious onset , grade-3(NYHA) , gradually progressive, Aggravated on walking and not relieved on rest.
  • History of left anterior septal deviation.
  • History of abdominal distension: Insidious onset, Not associated with pain, tenderness.
  • No history of vomiting, loose stools, constipation.
  • No History of orthopnea, PND, cough and palpitations 
  • No history of chest pain , cold, upper respiratory tract infection.

History of past illness: 

  • Not known case of diabetes mellitus, hypertension, asthma, thyroid disorder, TB
  • Known case of CVA- 1 year back
  • Known case of hydrouretronephrosis- 2 months back
Surgical History:
  • Patient underwent Lithotripsy 1 1/2 month back.

Personal history:

  • diet- mixed 
  • appetite- normal 
  • Bowels- regular 
  • Micturition- Normal
  • No allergies 
  • Alcohol - occasional drinker 1 year back
  • Not a smoker


Family history:

 Not significant 


GENERAL EXAMINATION


  • Patient is conscious , coherent and cooperative 
  • Moderately built and nourished
  • No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema


Vitals


  • Temperature: afebrile 
  • Pulse rate:80bpm
  • Respiration rate: 14 cpm
  • Bp: 110/80 mmhg

SYSTEMIC EXAMINATION


CVS


Elliptical chest 


No scars or engorged veins present


S1 and S2 heard


No murmurs heard


RESPIRATORY SYSTEM


Trachea is normal


Bilateral air entry present


Resonant note is present on percussion on all areas


Normal vesicular breath sounds heard




CNS


No focal neurological deficits present


Cranial, motor, sensory nerves are normal 



ABDOMEN


Abdomen is distended


Flanks are full


No tenderness present


Shifting dullness is present


Liver and spleen not palpable








Abdominal Distension:






INVESTIGATIONS










PROVISIONAL DIAGNOSIS


Ascites with shortness of breath due to?-



TREATMENT


Spironolactone

Paracentesis


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