78 year old male
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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.
78years old male came to casuality with
Chief complaints:
Difficulty in breathing since one month aggrevated since yesterday
History of presenting 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 (rod and plate fixation) since one month patient complaints of breathlessness (grade 3) insidious in onset gradually progressive aggrevated on walking 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.
Past HISTORY:
He has no history of hypertension and diabetes
No h/o asthma, epilepsy, tuberculosis.
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: blood transfusion 1 month back
Urethral striture dialation
General examination
Patient is conscious,cohorent , cooperative well known with time, place, person
He is well built and moderately nourish
Pallor present
Lymphadenopathy-right side
Peadal.edema- bilateral peadal edema with pitting type
VITALS :
On 30 march
Temp : 98.6F
Pulse rate-80bpm
Blood pressure :130/90mmhg
Respiratory rate :20 cpm
Spo2 : 96%
SYSTEMIC EXAMINATION
CVS :
on 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 thoracal
Dyspnea: present
Palpation: trachea -central
Percussion: dullness
Auscultation: basal crepitations are heard
In infra axillary and infra scapular area
Wheezing heard mammary region
Vesicular breath sounds
CNS: no focal neurological deficit
MANAGEMENT :
INVESTIGATIONS : haemogram ,LFt ,serum - creatinine,urea, electrolytes
x ray-PA , ECG ,2D ECHO
X ray :
ECG :
Provisional diagnosis:
? Heart failure with Post Aki ,? COPD , bilateral plural efusion
Treatment: fluid and salt restriction
Inj lasix 40mg iv/bd
Tab - oflox 200mg po/bd
Inj - pantop 40mg iv /od
Syrup -citralka 10ml-10ml-10ml (galss of water )
Moniter vitals
