Dr Bhavya
50 Years old male with SOB
Case
A 50 year old male patient farmer by occupation came to the department with
CHIEF COMPLAINTS :
- shortness of breath since 13 days
- complaints of edema in both lower limbs since 9 days
-Decreased urine output since 9 days
HISTORY OF PRESENTING ILLNESS:
Patient is apparently asymptomatic 13 days back then he developed
-Shortness of breath which was insidious in onset and progressed to Grade 4 ,aggrevated on lying down and walking and relieved in sitting position.
- He also developed bilateral pedal edema ,since 9 days which is pitting in nature which is insidious in onset and it is initially Grade 1 and presently progressed upto Grade4
-He also had decreased urine output since 9 days.
No history of chest pain,palpitations,syncope,fever, cough ,hemoptysis,burning micturition and knee pains.
PAST HISTORY:
10 years back -
History of fall from tree
3 years back -
Diagnosed with Tuberculosis and Diabetis mellitus
1 year back -
Noticed swelling in both legs and on consultation was diagnosed with Chronic kidney disease.
-Not a known case of ; Hypertension, thyroid, Asthma
TREATMENT HISTORY:
Drug history:
-NSAIDS intermittently to relieve neck pain
-Antitubercular therapy
- Metformin 500mg three times a day
Past surgical history:
No history of any surgeries in the
Past.
PERSONAL HISTORY:-
-Patient takes mixed diet
-Appetite is normal
-Sleep is adequate
-Bowel - regular
-Bladder- decreased urinary output since 9 days
-Addictions - occasionally alcohol consumption
-Daily routine:
He is farmer by occupation and used to go to work by waking up at 6 am and breakfast at 7 am ,completes work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm
He stayed at home since the fall from tree due to low backache
FAMILY HISTORY:-
no significant family history
ALLERGIC HISTORY:-
no allergies to any kind of drugs or food items
GENERAL EXAMINATION:-
Patient is conscious, coherent, and cooperative
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
-Pitting edema seen in both lower limbs
Supra clavicular: normal normal
Infra clavicular: normal normal
Mammary: normal normal
Infra axillary: normal decreased
Supra scapular: normal normal
Infra scapular: normal decreased
Inter scapular: normal normal
Infra clavicular: resonant resonant
Mammary: resonant resonant
Infra axillary: resonant dullnote
Supra scapular: resonant resonant
Infra scapular: resonant dullnote
Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Supra scapular: Normal Normal
Infra scapular: Normal decreased
Inter scapular: Normal normal
Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Supra scapular: Normal Normal
Infra scapular: Normal decreased
68Y/F WITH SOB
This is an a 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.
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
COMPLAINTS AND DURATION:
Pt c/o cough: 6 months
Shortness of breath= 4-5 months
HOPI:
-Patient was apparently normal untill 6months back.
then developed productive cough, insidious in onset gradually progressive with white colored mucoid sputum , relieved on taking medication and aggrevated later I.e., cough Increased mostly at night time around 3-4AM
- Shortness of breath: 4-5 monthly, insidious in onset and gradually progressed to grade-IV now. Increases on walking for few steps.
Orthopnoea present. - feels better on lying to lateral side.
- Pt also gives h/o PND
PAST HISTORY:
H/o decreased appetite: 4 months.
no h/o fever/ burning micturition/ pain abdomen / chest pain/ palpitations
No Decreased urine output/ pedal edema.
Not a k/c/o DM/HTN/TB/ Epilepsy / CVA / CAD/ thyroid diseases
- H/o fall 2 years back -> Right antle # - POP applied.
PERSONAL HISTORY:
Normal appetite, mixed diet with regular bowel and bladder habits and addiction of smoking
2-3beedis/day started 8years back ,stopped 2 years back
GENERAL EXAMINATION:
PT IS C/C/C
PALLOR: PRESENT
NO PEDAL EDEMA,ICTERUS,CYANOSIS,CLUBBING,
LYMPHADENOPATHY
VITALS ON ADMISSION:
PR-98 BPM
BP- 130/80MM HG
RR- 40 CPM
SPO2- 92% AT RA
GRBS - 133mg/dl
SYSTEMIC EXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.
PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.
ASCULTATION: BOWEL SOUNDS - HEARD
2)RESPIRATORY SYSTEM:
INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT BIL
ASCULTATION: BAE + , NVBS HEARD
3) CVS:
INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.
ASCULTATION: S1S2 +,NO MURMURS
4) CNS:
PATIENT WAS C/C/C.
HIGHER MENTAL FUNCTIONS- INTACT
GCS - E4V5M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,
MOTOR SYSTEM:
TONE- NORMAL,
POWER- 5/5 IN ALL LIMBS REFLEXES:
B/L REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+
INVESTIGATIONS :
ECG
Chest x ray
Sputum culture
DIAGNOSIS:
TREATMENT:
1.Nebulisation with DUOLIN 4th hrly
BUDECORT 8th hrly
2.Syp: ARCORYL-LS
2TBSP TID.
3.T LEVOCETRIZINE PO BD
8AM —————-8Pm
4.T. PAN 40mg PO OD
7am —x——x
5.SYRUP CREMAFFIN PO HS 10ml
