A 78 yr old women came to opd with abdominal pain and shortness of breath

 Hi I am, AnirudhManne (roll no:11), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

Case sheet 

CHIEF COMPLAINTS

A female patient of age 78yrs old came to opd with chief complaints of Shortness of breath Grade 2 to 3.

She came with complaints of left iliac fossa pain radiating to left hypochondrium.

HISTORY OF PRESENT ILNESS

The patient was apparently asymptomatic 5 months back she then developed shortness of breath(grade2-grade3) not associated with any cough then was admitted in hospital where she was treated then. And used inhaler for asthma she stopped using it 10days back

The patient again developed abdominal pain in the left lumbar region radiating to the hypochondrium  area and with shortness of breath on walking.

ONSET OF PAIN was acute 

DURATION OF pain since 6days 

The pain was aggregated on bending down

PAST HISTORY

Patient is a know case of HTN since the past 25 years and asthma

No history of TB , DM, Epilepsy

PERSONAL HISTORY

Diet mixed

Appetite decreased

Sleep adequate

Bowel and bladder movements regular

GENERAL EXAMINATION

The patient was conscious coherent and well oriented to time and place 

No pallor

No icterus 

No cyanosis 

No lymphadenopathy

No pedal oedema

RESPIRATORY SYSTEM EXAMINATION 

Inspection:

The trachea appears to be central 

The chest is bilaterally symmetrical 

No scars no sinuses and no visible palpitations are seen

Palpation:

Trachea is central in position

 The chest movement are bilaterally symmetrical and equal on both sides

Percussion:

 Resonant:

PROVISIONAL DIAGNOSIS 

Renal caliculi

INVESTIGATIONS DONE: