Breathlessness and Epigastric pain

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 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. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

Chief complaints:
Breathlessness since 10days 
Epigastric pain since 4 days

History of present illness:
Patient was asymptomatic 10 years back and developed immense cough which was insidious in onset and gradual in progression 
 Later he visited hospital and diagnosed with tb 
He started his 6 month course of att 

He then developed a swelling in the right scrotum  4yrs back which was gradual jn nature 
This was diagnosed to be hydroceole 
 He underwent surgery 
His breathlessness was on and off since then 
Would increased due to alcohol 

10 days back he developed severe sob and got admitted in the hospital and was diagnosed with severe tb in 3/11/22
Sob was grade 4 and cough was productive 
No reliving factors seen 

Past history:
No history of dm,hypertension,asthma,
History of tb 
H/o hydroceole surgery 

Personal history:
Appetite:lost
Addictions present 

Family history:
No significant family history 

General examination:
Weight: 50 kg 
Pt is conscious,coherent,cooperative well oriented with time place and person 

Palor absent 
Icterusabsenr
Lymphedenopathy absent 

Temperature:99.7
Pulse rate:126
Rr: 36
Bp:140/70
Spo2 :97

Systemic:
CVS 
No murmurs heard
S1 S2 heard

Respiratory system
Dyspnea are present
Wheezing  is absent
Position of trachea central


Abdomen
Shape scaphoid
Tenderness present
Epigastric pain present
Central tenderness present
No free fluid fluid
Bowel sounds heard



CNS examinations
Patient is conscious
No neck stiffness
Cranial nerve examination normal


Diagnosis


 severe anterior wall mi 
Pulmonary TB relapse
Renal calculi 

Treatment

Nebulisation with budecort 
Injection lasix 
Tab clopidegrel 
Tablet eco sporin 












Grades of breathlessness 

 

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