A 65 years old male patient with SHORTNESS OF BREATH since 6 days….


Date:3/12/22


This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.


This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.


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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.


                     CASE REPORT


A 65 years old male patient who is a resident of 

Choutuppal was once a farmer by occupation 

(stopped working 6 years ago) came to Medicine 

OPD with chief complaints of ;

(Date of history taking and examination - 2/12/22)

> Lower Abdominal pain for 6 days 

> Shortness of breath for 6days

HISTORY OF PRESENTING ILLNESS :


The patient was apparently asymptomatic 25 years ago, then he developed cough which was blood stained for which he was diagnosed with Tuberculosis and was on Anti tubercular therapy for 6 months then after he was said that he is free from disease.

2 years back he started having Shortness of breath (Grade 2) , which was insidious in onset and relieved temporarily on medication (Drug & Dosage unknown).

6 months ago he again developed shortness of breath (Grade 2) which was insidious in onset and he was taken to higher centre, where he was prescribed a medication that he used only on the aggravation of shortness of breath.

Then after 5 months ago he suffered from an accident which was associated with fracture of left tibia and left tibia, for this he was managed with POP casting (45 days) and supplementation of calcium tablets (Dose: 500mg).

Also 6 days ago he also developed diffuse pain over the abdomen which was insidious in onset,  non radiating and was subsided now.

NO H/O fever with chills and rigor                       

NO H/O anorexia, nausea, vomiting                           

NO H/O loss of weight  

Then 6 days ago he developed shortness of breath of grade 3, which was insidious in onset and relieved temporarily on medication ( Drug not known).

There is also a history of diarrhoea since 2 days.(under evaluation )

PAST HISTORY :

History of Pulmonary Tuberculosis 25 yrs ago.

No history of DM, hypertension, asthma, epilepsy.

No history of previous surgeries      

PERSONAL HISTORY :         

Diet : Mixed

Appetite : Decreased since 1year

Bowel & Bladder habits : Regular

Sleep : inadequate

Addictions : None from 20 years (Before alcohol and 
smoking)

No known food allergies

FAMILY HISTORY :

No relevant family history

TREATMENT HISTORY :
           
Not significant
 
GENERAL EXAMINATION :

Patient is conscious, coherent and co operative well oriented to time place and person.

Moderately built and nourished

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - No palpable lymph nodes

Edema - absent




VITALS :

Temperature - afebrile

BP - 120/80 mmHg

RR - 24 cpm

PR - 78 bpm

SpO2 - 96?????










RESPIRATORY SYSTEM :

INSPECTION :

Shape of chest - Elliptical, B/L symmetrical.

Trachea position central

Chest movements - Abdomino thoracic type with no involvement of accessory muscles

No scars over the chest

PALPITATION :

(All inspectory findings are confirmed)

No tenderness

Expansion of chest equal in all planes

PERCUSSION :

Resonant tone all over the chest except infra axillary area.

AUSCULTATION :

Bilateral vesicular breath sounds heard in all areas except the left infra axillary where there is decreased breath sounds.

PER ABDOMEN :

INSPECTION :

(All 9 regions are examined)

Shape - scaphoid

Abdominal distension - absent

Skin over the abdomen - normal 

No engorged veins

PALPATION :

No tenderness

No hepatomegaly and splenomegaly

PERCUSSION :

Normal

AUSCULTATION : 

Bowel sounds - heard

CARDIOVASCULAR SYSTEM :

INSPECTION :

No visible apex beat / pulsations

No scars, engorged veins

PALPATION :

Apex beat diffuse 

No palpable murmurs / thrills

AUSCULTATION :

S1 and S2 heard ; No murmurs.

PROVISIONAL DIAGNOSIS :

Cor Pulmonale Heart failure ( mid range preserved ejection fraction EF 52%)                                      With anemia under evaluation                                     With Chronic Kidney disease (heart failure and cystic kidney disease)                                          With history of pulmonary tuberculosis 25 years ago.


INVESTIGATIONS :

29/11/22


30/11/22










1/12/22






 









Stool analysis : 



TREATMENT :


Head end elevation up to 30 degrees

supplementation if spo2

<90%

MONITOR 4- hrly

NEB - SALBUTAMOL 4 hrly

FEVER CHART 4 th hrly 

InJ LASIX 4O mg

ORS sachets 



Comments

Popular posts from this blog

A 45 YRS OLD MALE PATIENT WITH ALTERED SENSORIUM

A 45 year old female with Fever a/w chills

A 70 YRS OLD FEMALE WITH ALTERED SENSORIUM