GM case 16. 85 year male with complaints of SOB since 2 days
Hi, I am P.Kathyayani, 5th sem medical student. This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatever.
Chief Complaint:
-85 year old male came to OPD with chief complaints of shortness of breath since 2 days
-Complaints of bloating since yesterday
-Complaints of decreased urine output since Morning.
History of Present Illness:
Patient was apparently asymptomatic 2 days back then developed difficulty in breathing which is insidious in onset gradually progressive
H/O PND, orthopnea present
H/o pedal edema present
H/o abdominal distension present
No H/o fever with pain, sore throat
No H/o involuntary movement
No H/o skin manifestations like rash, nodules
No H/o Recurrent respiratory infection
Syncope
No H/o Hemoptysis
No History of chest pain ; palpitations; loss of consciousness
Daily Routine:
Before he got sick, he used to wake up at 5am every morning, eat breakfast of rice and curry and leave for work by 8.30am. He is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at his workplace. He used to reach home by 7 or 8pm after which eat and sleep by 11pm.
After he got sick, he stopped going to work and stayed at home, following which he was admitted into the hospital.
Past History:
No similar complaints in the past
Not a k/c/o DM, HTN, CAD, CVA,TB,Thyroid,asthma, epilepsy.
Surgical history: no surgical history
Personal History:
- married
- decreased appetite
- mixed diet
- regular bowels
- micturition : decreased
- no known allergies
- addictions: chronic smoker of chutta which he stopped 6 years back due to complaint of hemoptysis .
Family History: no significant family history
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- edema of feet: present
-no malnutrition
-no dehydration
Vitals:
- Temperature: afebrile
- Pulse: 110 beats/ min
- RR: 32cycles/min
- BP: 140/80 mm Hg
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- no wheeze
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- bowel sounds: present
- genitals: normal
- speculum examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
RBS - 134 mg/dl
B.urea - 53 mg/dl
S.Cr - 2.4 mg/dl
Na - 140 mEq/L
K - 4.3mEq/L
Cl- 103mEq/L
CUE -
Albumin ++++
Sugar - Nil
Pus cells - 8-9 cells
Epi cells - 2-3 cells
RBC :- 10-12 cells
Hb- 13.0
TLC - 18,000
MCV - 92
MCH - 30.7
ÐœCHC - 34.0
PLT - 2.56 LAKHS
ECG:
X-Ray:
Provisional Diagnosis:
Acute exacerbation of COPD with acute cor pulmonale with De Novo DM II and hypertension.
Treatment:
1.INJ LASIX 40 mg IV/BD IF SDP>110mmHg
2.INJ AUGMENTIN 1.2 gm IV/BD
3.Intermittent Bipap
4.TAB AZITHROMYCIN 500 mg PO/O
5.INJ HYDROCORT 100 mg IV/TID
6.Inj aminophylline 500 mg IV / SOS
7.INJ HAI S/C TID ( inform Grbs)
8.Salt restriction < 2g / day; fluid restriction < 1.5
9.Nebulisation with budecort; mucomist
10.Inj N ACETYL CYSTEINE 400mg IV / SOS
11.TAB ECOSPIRIN AV 75/10 Po/HS
