HistoryTaking in Internal Medicine

[SUMAN-SAJAN]

PARTICULARS OF PATIENT

Name : Mana Maya Shrestha
Age : 60
Sex : F
Address : Dillibazar
Religion : Hindu
Occupation : House Wife
Education : no formal education
DOA :6 days back
MOA : ER
DOE : 10th jan 2007

CHIEF COMPLAINTS

shortness of breath for 1 month
cough for 1 month
swelling of legs, face and sacrum for 1 month


HOPI

According to the patient this is her third episode of hospital admission for shortness of breath .
Her symptoms deteriorated 1 month back with SOB , insidious in onset, progressive in nature , SOB at lying position present , no night disturbances, NYHA grade IV dyspnoea, aggravated by cold and dust , relieved by inhaler,associated with cough .
Cough was insidious in onset,15-20 bouts per day , productive in nature , white sputum, no foul smelling , spoonful in amount , severe during night , no postural variation , no blood stained , aggravated by cold and no relieving factors known.

No h/o fever, vomiting and chest pain.

Also complains of swelling of face , legs and the sacrum.
Swelling started from legs, gradual in onset, progressive in nature , later spread to the sacral region and there was puffiness of face also.

Urine output is normal.

PAST HISTORY

Admitted and treated at KMCTH 2 years back , which was her first episode and 1 year back for the second episode.

No history of past surgeries .

PERSONAL HISTORY

B:normal
A:normal
S:adequate
U:normal

Smoking: 3 pack year
Occasional alcohol consumer


MENSTRUAL HISTORY

Menarche:15 years
Menopause: 50 years
No h/o dysmenorrhoea

FAMILY HISTORY
No h/o similar episode of illness in the family
No h/o DM, HTn, TB

SOCIOECONOMIC HISTORY
middle class family
3 members
sanitation - good
kerosone (stove )as fuel

ALLERGY HISTORY
Allergic to cold

TREATMENT HISTORY

hydrocortisone
ipratopium bromide
cortilone , glucocorticoid
amoxycilli




CASE SUMMARY

A 60 years old female , previously non hypertensive and non diabetic but a smoker was admitted with complain of shotness of breath for 1 month, progressive in nature,orthopnea present , PND absent, NYHA grade IV dyspnoea.
She also had cough , productive , moderate amount of sputum, no blood staining.
She had swelling of the legs and sacrum, puffiness of the face and h/o similar episode 2 years back.
No h/o fever , chest pain. Bowel and bladder habit normal.


ITS UR TURN NOW :

What are the differential diagnosis ?
What is your provisional diagnosis ?
What are the investigations to be done?
What are the management steps?