A 80 yr old male with shortness of breath
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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 80 yr old male resident of nakrekal , farmer by occupation presented to the OPD with complaints of
Difficulty in breathing since 1 month
Cough with sputum since 7 days
HISTORY OF PRESENTING ILLNESS
Patient was asymptomatic 4 yrs back , then he developed swelling in the right leg which was diagnosed as filariasis for which he did not use any medication
3 yrs ago he had h/o trauma in the left leg which was operated
Recently complaint of the patient since one month is shortness of breath which was insidious in onset , gradually progressive in nature , which aggravated on walking and since 7 days it is not relieved on sitting and lying down and no seasonal variation
H/o decrease in urine since 20 days for which urethral structure dilatation was done
No h/o fever , weight loss , burning micturition
PAST HISTORY
Not a known case of diabetes , hypertension , asthma , epilepsy , tuberculosis
H/o previous surgery ( rod and plate fixation ) for trauma of left leg
PERSONAL HISTORY
He is an elderly male who was farmer by occupation but stopped work since 15 yrs .
His daily routine is as follows
Wakes up at 6:00 in the morning
Do his daily routine
Refrained from his excess physical activity
Appetite decreased
Diet mixed
Sleep adequate
Bladder movements decreased
Bowel movements are regular
Addictions - smoking in the past but stopped 15 yrs ago
Alcohol drinking in the past stopped 1 yr ago
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
Patient was conscious coherent cooperative and well oriented to time place and person
He is well built and moderately nourished
Pallor - present
Bilateral edema present of grade 3 which is pitting type
No signs of icterus , cyanosis , clubbing , lymphadenopathy
VITALS:
Temperature -98.6 F
Pulse rate-80 bpm
Blood pressure :130/90mm.hg
Respiratory rate :20 cpm
Spo2-96 % room air
SYSTEMIC EXAMINATION
CVS
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
PROVISIONAL DIAGNOSIS
Dilated cardiomyopathy
Bilateral syn pneumonic effusion
With right leg filariasis ( 4yrs back)
INVESTIGATIONS
30/11/22
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