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.
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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.
Mr. xyz aged 60 yrs presented with chief complaints of short of breath since 1 week and cough with sputum since 8 days
History of present of illness:
Mr. xyz was apparently asymptomatic 4 yrs back, then he developed swelling in the right leg which was insidious in onset, progressive and pitting type and was diagnosed as filariasis for no intervention has been done. He had history of trauma to the left leg 3 yrs back which was been operated and corrected the multiple fractures. Patient had history of decreased urine output since 20 days due to urethral stricture and treatment by dilation. Recently he presented with shortness of breath which is insidious in onset gradually progressive initially it was grade 2 Mmrc then grade 4 Mmrc and now after treating with Tab. lasix 40 mg Tab ecospirin 75 mg the grade returned to grade 2 Mmrc and history of productive cough mostly in the evenings which has mucoid sputum and it is scanty. History of wheezing is also present .No history of fever with chills, weight loss, nausea vomiting. There is history of Orthopnea and Paroxysmal nocturnal dyspnea 1 week. No history of chest pain presently. No history of palpitations and syncopal attacks. And recently 1 day ago he had developed pain in lt iliac fossa and then it is diagnosed as intramuscular abscess by the surgical department and is under treatment by aspiration with gram staining which is under further evaluation.
Past history:
no history of similar complaints in the past and no diabetes, hypertension, asthma, epilepsy, tb.
Personal history:
He is an elderly male who was farmer by occupation and stopped working since 15 yrs. His daily routine is: Wakes up at 6:00am in the morning and does his daily routine and refrained from his excess physical activity.
Diet: mixed
Appetite: decreased
Sleep : adequate
Bladder movements decreased
Bowel movements are regular
Smoking in the past 10 cigaretes per day 15 yrs ago
alcohol of 150 ml occasionally but stopped 1 yr ago
No History of food and drug allergies
Family history:
no relevant family history
General Physical Examination:
Patient is conscious< coherent, cooperative, well oriented to time, place, person.
moderately built and nourished
pallor present
no icterus, cyanosis, clubbing, lymphadenopathy.
bilateral pedal edema grade 3
Vitals:
temperature: afebrile
heart rate: 80bpm
respiratory rate: 20cpm
Spo2: 96%
Systemic Examination:
Cardiovascular system:
Jvp is elevated which is 7-8cm of H2O
all arterial pulses are palpated with decreased rate regularly irregular rhythm
no radio-femoral and radio-radial delay.
on examination of precordium
inspection:
shape of chest is normal
position of trachea is central
no visible pulsations seen
no engorged veins seen
no scars and sinuses present
palpation:
no local rise of temperature and no tenderness felt
apex beat is palpated in 6th intercostal space 1cm away from mid-clavicular line
no palpable thrills, no parasternal heaving
on auscultation s1 best heard at tricuspid and mitral area s2 best heard in aortic and pulmonary area
s3gallop heard at lt lower parasternal area with the bell
no murmurs, clicks, snaps, bruits and venous humms
Respiratory system:
on examination of upper respiratory tract no abnormalities in nose and paranasal sinuses are clear
oral cavity is normal.
on examination of lower respiratory tract:
inspection:
chest shape is elliptical and b/l symmetrical moves with respiration
no shrugging of shoulders
spino-scapular distance is equal on both sides
palpation:
no local rise of temperature and no tenderness
all inspiratory findings are confirmed
tactile vocal fremitus decreased in infra-axillary and infrascapular regions
on percussion:
dull note in infraaxillary and unfrascapular regions
on auscultation:
b/l basal coarse crepitations are heard rt > lt
vesicular breath sounds in all areas expect in lower lobes of lung
Nervous system:
no focal neurological deficits
Per abdomen:
shape is scaphoid
tenderness at lt iliac fossa
no shifting dullness and no fluid thrill
no guarding and rigidity
no palpable liver, spleen, kidney, gall bladder
on auscultation:
bowel sounds heard and no bruits
Clinical images:
Provisional Diagnosis:
Heart failure
B/L lower lobes pneumonia
with previous right leg filariasis
Investigations:
IRREGULARLY IRREGULAR RHYTHM
AXIS IS NORMAL(BETWEEN -30DEG TO +110DEG)
ABSENT P WAVE: SUGGESTING OF ATRIAL FIBRILLATION
QRS COMPLEX NORMAL
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
Neb. C duolin - 4th hourly
budecort - 5th hourly
Final diagnosis:
Heart failure with reduced ejection fraction with atrial fibrillation
b/l pneumonic effusion
lt iliac fossa intramuscular abscess under evaluation
Inj. Augmentin, 1.2 gm, IV, TID