A case of 65 year old male with complaints of abdominal pain and 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 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 year old male patient came to opd with chief complaints of shortness of breath and abdominal pain since 5 days
HOPI
25 years back: patient was apparently asymptomatic 25 years back, then he developed cough with hemoptysis.
He was then diagnosed positive with pulmonary tuberculosis, for which he took anti tuberculosis therapy for 6
2 years back: he started experiencing shortness of breath which was insidious in onset aggrevated on doing physical work and relieved by resting. SOB is of grade 2
He went to a local doctor with complaints of sob and received medication, which helped in reducing the symptoms temporarily
6 months back: he again developed shortness of breath which was insidious in onset aggrevated with physical work and relieved by resting
Then he was taken to higher centre where he was given drugs for shortness of breath. He was not compliant with the treatment regimen, he only took medication when the sob increased.
5 months back: he met with an accident and sustained a left tibial fracture.
It was managed with a POP cast for 45 days
7 days back: he developed shortness of breath ( grade 3 ) and diffuse abdominal pain, which is insidious in onset, non radiating, relieved on medication
SOB is associated with productive cough with scanty white sputum, fatigue and sweating.
NO HISTORY OF nausea, vomiting, anorexia, weight loss, jaundice, fever, hematuria, oliguria.
NO HISTORY OF: palpitations, orthopnea.
PAST HISTORY
patient suffered with tuberculosis 25 years back
He is a known case of hypertension since 3 years
No history of diabetes, asthma, epilepsy,
No history of prolonged hospital stay
No history of previous surgeries
PERSONAL HISTORY
diet: mixed
Appetite :decreased
Sleep: adequate
Bowel and bladder: regular
Addictions: stopped alcohol and smoking 20 years back
FAMILY HISTORY
no similar complaints in family
ALLERGY HISTORY
No known allergies to food and drugs
GENERAL EXAMINATION
Patient is lying in supine position comfortably on the bed
He is conscious coherent and cooperative, well oriented with time place and person.
Pallor +
No icterus, Clubbing, cyanosis, lymphadenopathy, edema
Vitals:
Temperature 98°f
Blood pressure 110/80 mm Hg
Respiratory rate 22 cpm
Pulse rate 95 bpm
Spo2 98%
Peripheral pulses are felt, no radio radial delay and radio femoral delay.
SYSTEMIC EXAMINATION
Respiratory system
INSPECTION:
Shape of Chest - normal
Trachea position central
Movements of the chest: bilaterally symmetrical
Type- abdomino thoracic type no accessory muscles involved.
Skin over the chest: no engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.
PALPATION:
No local rise in Temperature and tenderness
All inspectory findings are confirmed
Tactile vocal fremitus: bilaterally resonant and symmetrical in all areas
PERCUSSION:
Resonant all over the chest except infraxillary area
AUSCULTATION:
Normal vesicular breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.
Abdominal examination
INSPECTION:
Shape :scaphoid
No Distention of Abdomen
Flanks- full
Umbilicus- normal
The skin over the abdomen: normal
No engorged veins, visible pulsations, or hernia orifices.
PALPATION
Abdomen is soft and diffusely tender
No hepatosplenomegaly, no guarding and rigidity
PERCUSSION
normal: tympanic note
AUSCULTATION: Normal Bowel sounds are heard
CVS examination
INSPECTION
Precordial area appears to be normal
No visible scars, sinuses, and engorged veins
Apex beat was not visible
PALPATION
All inspector findings were confirmed.
Apex Beat - diffuse
No palpable murmurs (thrills)
AUSCULTATION:-
S 1; S 2 heard in all areas
No murmurs, no abnormal sounds
INVESTIGATIONS
DIAGNOSIS
Heart failure with mid range reduced ejection fraction
With Cystic kidney disease
1.inj lasix 40 mg iv/bd
2.tab metxl 25mg po/od
3.tab pan 40 mg po/od
4.tab Ultracet po/bd
5.tab clopitab-a po/od
6.tab atorvastatin 20 mg po/od
7.tab darolac po/tid
8.nebulization with
Duolin 12th hrly
Budecort 8th hrly
9.IVF-NS 50 ml/hr
10. O2 supplementation 4 th hrly
11. Vitals every 4th hrly
SOAP NOTES
5/11/22
S: c/o Shortness of breath
O:
Pt is ccc
Afebrile
BP:110/70mm hg
PR:90bpm
RR:20 cpm
CVS: S1 S2 heard
GIT: soft , non tender
RS: BAE+
GRBS:95 mg/dl
A:
Heart failure with resolved ejection fraction EF 39%, With moderate LV dysfunction, acute GE (resolved ) , multifocal atrial tachycardia 2° to COPD(resolved) ,With history of pulmonary tuberculosis 25 years ago, AKI on CKD(2° to PCKD),with COPD and rigth upper lobe collapse
P:
1) inj. Lasik 40mg iv /Bd/D
2)Tab . MGTXL 20mg PO/OD
3)Tab. Pan 40 PO/OD
4)Tab.Ultracet PO/OD
5)Tab. Clopitab A
6)Tab . Atrovastatin
7)Tab.Darolac
8)Neb . Duolin
Budicort
9)iv ns -50/ml/hr iv infusion
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