General Medicine (Case 1)

 Hello, 

This is S Raaga, I am using this online blog to give a detailed outlook at the patient with his consent.This will help in keeping an online record of the cases covered during the clinical hours.

Case Sheet - 

A 61 year old man presented to the hospital complaining shortness of breath and cough and pain of the chest and abdomen during coughing.

Chief Complaints - 

Shortness of breath , Cough(duration - 10-15 days),Cough increasing at night time, Chest pain particularly during coughing , pain in the abdomenal region.

History of Present Illness - 

Patient was apparently not having any discomfort before the onset of cough and breathless with which he presented to the hospital.Cough with thick sputum since 10 days, Shortness of Breath , Diurnal increase in cough, Burning sensation in Urine are of major concern, No fever, Reduced appetite, Fatigue.

The patient is not hypertensive or hypotensive 

The patient is not Diabetic

Past History- 

The patient has never been admitted into the hospital with such a complaint or for any other health conditions and is not under any medication for any disease.

Personal History -

Diet - Consumes Vegetarian and non-vegetarian food

Appetite- Reduced since 10 days 

Diegestion - Normal 

Bladder and bowel - Frequency of urination and stools is normal,  Burning sensation in Urine since 10 days, Normal stools.

Sleep cycle - Due to diurnal disturbance by cough lack of sleep and associated tiresomeness.

Allergy to drugs - No allergies to any drugs as per the patient.

Alcohol consumption- Negative

Tobacco consumption- The patient smokes cigarettes since the past 30 years.

Treatment History - Nil

Family history - Nil

General Examination - 

Inspection - No swelling

Provitional Diagnosis -

Respiratory illness associated with heart disease due to chronic smoking. 

Chronic obstructive pulmonary disease which includes Emphysema and Chronic bronchitis.

Questions around the Patient-

How effective is the given medication?

Must the patient come for regular health check up?

What measures must the patient take to prevent further invasion of the disease ?