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















1/12/22












2/12/22




3/12/22





4/12/22
 















 X RAY 




TREATMENT 

Inj. Augmentin, 1.2 gm, IV, TID

Tab. Azithra, 500 mg, OD, Per oral

Tab. Pantop, 40 mg, OD, per oral

Tab. Met xl, 25 mg, OD, per oral

Tab. Montair LC, per oral

Tab. Ecospirin, 75 mg

Tab. Ultracet, per oral, QID

Tab. Lasix, 40 mg, BD

Neb. C duolin - 4th hourly

            budecort - 5th hourly

Syrup Grillinctus, 10 ml








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