78 year old male with SOB and cough
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input
A 78 yr old male patient,resident of nakrekal,farmer by occupation presented with chief complaints of
SHORTNESS OF BREATH since 1 month
Which aggravated since 1 day
COUGH since 4 days
HISTORY OF PRESENTING ILLNESS:
pt was apparently asymptomatic 4 yrs ago
Then he developed swelling in right leg which was diagnosed as filariasis .no medication was taken for this condition.
3 yrs back pt had a trauma to left leg and was operated (rod and plate fixation done)
Since 1 month pt complains of shortness of breath which was insidious in onset gradual in progression aggravated on walking and no seasonal variation.
15days back patient had decreased urinary out put for which urethral stiture dialation done one week back
H/o cough since 4 days
H/o orthopnea since 3 days
H/o weight loss from 2 week
No h/o fever,burning micurition
H/o urgency to urination, increased frequency of urination.
6months back he had localized biilateral swelling on legs
Exertional sob
Past HISTORY:
He has no history of hypertension, diabetes
,asthma, epilepsy, tuberculosis.
H/o trauma in left leg after he fell due to loss of consciousness after getting fever
Treated by internal fixtures
H/o right leg swelling due to filariasis
No previous hospitalizations
PERSONAL HISTORY:
He is an elderly male who was previously a farmer but not doing any work from past 15 years .In home he gets up at 6 ,do his daily routine activities and sit quietly.
Apettite-decreased
Diet- mixed
Bladder- decreased
Bowel -normal
Sleep-disturbed
Addictions- Smoking-stopped 15 years ago
Alchol-stopped 1yr ago
Family history: Not significant
GENERAL PHYSICAL EXAMINATION
Pt is consious,coherent,cooperative and well oriented to time,place and person
He is well built and moderately nourished
Pallor present
bilateral peadal edema(pitting type)
No icterus,cyanosis, clubbing
VITALS:
Temperature -98.6 F
Pulse rate-80 bpm
Blood pressure in sitting position:
130/90mm.hg
Respiratory rate :20 cpm
Spo2-96 %
SYSTEMIC EXAMINATION
CVS
on inspection
No visible heart pulsations
Palpation:
Apex beat at 6th intercoastal space
Auscultation: S1,s2 are heard
Rhythm regularly irregular
Respiratory system:
Inspection: chest shape normal,
Breath movements -abdominal thoracic
Dysponea - present
Palpation: trachea -central
Percussion: dull note in infra axillary and infra scapular regions
Auscultation: coarse basal crepitations are heard
In infra axillary and infra scapular area
Wheezing heard in mammary region
Vesicular breath sounds.
Abdominal examination
Shape - scaphoid
Tenderness - no
Free fluid - no
Liver - not palpable
Spleen- not palpable
CNS: no focal neurological deficits
INVESTIGATIONS:
USG
ECG
Chest X ray
PROVISIONAL DIAGNOSIS:
Heart failure(?)
COPD(?)
B/L pleural effusion
Post renal AKI
Plan of treatment
Fluid and salt restriction
Inj.lasix 40mg iv/BD
Inj.pan 40mg iv/OD
T.Azithro 500mg/OD
Monitor vitals 6th hourly
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