75 year old male with SOB

 

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan. 

Case Discussion. 

75 year old male resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days.

History of presenting illness.

Patient was apparently asymptomatic 2 years ago ,later he developed SOB,pedal edema and generalised weakness for 2 weeks and for which he was treated.

2 months ago he developed cough with sputum , which is white in color, not blood stained and non foul smelling. And also SOB which gradually progressed from Grade 3 to Grade 4 ,one month ago.

He also developed facial puffiness 20 days back . Along with pedal edema with is of pitting type.He has chest pain since 10 days which aggrevated with SOB.

No H/O fever with rash,hemoptysis,nausea,vomiting,constipation.

Past history:

Not a k/c/o HTN,DM,Thyroid,asthma,epilepsy,Congenital heart Disease. 

Personal history:

Diet-mixed

Appetite-normal

Bowel and bladder movements-Regular

Sleep -adequate

Addictions-chronic smoker since 30 yrs (4 per day)

Occasionally alcohol 

GENERAL EXAMINATION : 

Patient is conscious , coherent and cooperative and well oriented to time place 

and person, 

Thin built and moderately nourished

Pallor- present

Bilateral Pedal Edema-present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Weight loss of 4kgs within 1 day after diuretics. 

 

VITALS :

Temperature-   98.6 F

Pulse rate- 92 bpm(Irregularly regular)

Respiratory rate-14cpm

BP- 110/80 mm Hg

Spo2-  112%

GRBS-130 mg 

Systemic Examination:

 Respiratory system. 

Inspection- 

Shape of chest-elliptical and symmetrical

Position of trachea-midline.

Bilateral symmetrical chest movements on respiration.

Palpation-

No local rise of temperature and no tenderness.

Apexbeat

TVF

Percussion-

Ascultation-

crepts heard over right infra mammary and infra axillary regions.

 

Investigations:

ECG

T wave absent, narrowed QRS complex

Hemogram:-

Hb- 6.2

Microcytic hypochromic with anisopoikilocytosis

RBC-3million

Platelets-2 lakhs

Electrolytes

Na+2  -145

K+ -  4.2

Cl-  -100

Blood urea - 42mg/dl

Serum creatinine - 1mg/dl

Provisional diagnosis:

Acute on Chronic COPD with Right Heart Failure .

 

Treatment: