A 78 year Old male came to gm OPD with shortness of breath and cough




 This 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.






This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.





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.
Chief complaints
A 78 year old Male patient came to opd with chief complaints of shortness of breath  since 30 days

History of present illness:

Patient was apparently asymptomatic 4 yr back and then he developed right leg swelling(filariasis) not taken any medication
3yrs patient had history of trauma to left leg (internal fixtures ) 
since one month patient complaints of breathlessness (grade 3) insidious in onset gradually progressive aggrevated on walking and no seasonal variation. 

15days back patient had decreased urinary out put for which urethral stiture dialation done one week back 


H/o orthopnea since 3 days

H/o weight loss from 2 week

 H/o  dry cough since 4 days
 No h/o fever

 No H/o burning micurition
 
H/o urgency to urination, increased frequency of urination.

No H/o adequate sleep(OSA?)

6months back he has localized biilateral swelling on of legs



Exertional sob



Past HISTORY:

He has no history of  hypertension and diabetes 

No h/o asthma, epilepsy, tuberculosis. 

H/o trauma in left leg after he fell due to loss of consciousness after getting fever
Treated by internal fixtures

H/o right leg swelling due to filariasis diagnosed in a medical camp

No previous hospitalizations



Personal history:

 He is an elderly male not doing any work from past 15 years .he terminated his work as a farmer as ageing . In home he gets up at 6 ,do his daily routine activities and sit quietly.

Apettite-decreased
Diet- mixed
Bladder- decreased
Bowel -normal

Addictions-  Smoking-stopped 15 years ago
Alchol-stopped 1yr ago

Family history: No significant

Treatment history: No similar history
Blood transfusion -10 days ago(?)

General examination

He is well built and moderately nourished


Pallor present

Lymphedenopathy-No

Peadal.edema- bilateral peadal edema with pitting type

No icterus,cyanosis, clubbing 


VITALS:

On 30 march ,

Temperature -98.6 F

Pulse rate-80 bpm

Blood pressure in sitting position:
130/90mm.hg

Respiratory rate :20 cpm
Spo2-96 %



SYSTEMIC EXAMINATION

CVS

on inspection

No visible heart pulsations

Jvp

Palpation:

Apex beat at 6th intercoastal space

Auscultation: S1,s2 are heard
Rhythm regularly irregular



Respiratory system:

Inspection: chest shape normal, 
Breath movements -abdominal thoracal
 Dysponea - present

Palpation: trachea -central

Auscultation: basal crepitations are heard
In infra axillary and infra scapular area
 
Wheezing heard 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


MANAGEMENT 

INVESTIGATIONS:

Haemogram

LFT

SERUM -creatinine
               Urea 
               Electrolytes

Chest xray

2d ECHO

ECG





Interpreation:

Echo report-

ECG findings

Provisional diagnosis
Heart failure(?) WITH POST AKI
COPD(?)


Treatment: fluid and salt restriction 

Inj lasix 40mg iv/bd 

Tab - oflox 200mg po/bd 

Inj - pantop 40mg iv /od 

Syrup -citracka 10ml-10ml-10ml (galss of water )

Moniter vitals 
  









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