73yr Male with Breathlessness

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

PRESENTING COMPLAINTS:

Breathlessness since 10 days.

Epigastric pain since 4 days.

HISTORY OF PRESENTING ILLNESS:

Patient was asymptomatic 12years back and then developed cough for which he went to hospital and was diagnosed with tuberculosis.

4years back patient had developed swelling in his scrotum, for which he underwent hydrocele surgery. Since 2 months patient is having breathlessness, on and off for which he used to go to nearby RMP and use medication and used to drink alcohol to get sleep. 

Patient had developed severe shortness of breath 10 days back and got admitted in area govt. hospital and was diagnosed with tuberculosis (CBNAAT) on 3/11/22. SOB of grade IV, gradual chronic onset, associated with cough(productive and white in colour), no relieving factors.

No H/O fever,Vomitings,Headache,Burning micturation

HISTORY OF PAST ILLNESS:

Not Known case of HTN, DM, Asthma, Epilepsy 

Known case of TB(12yrs back, used ATT medication for 6months)

PERSONAL HISTORY:

Diet: mixed

Appetite: lost since 10 days.

Sleep: inadequate

Bowel and bladder: irregular

Addictions:

Alcohol- Drinks regularly since 40years.

Tobacco- Smoked for 30 years and stopped 12 years back.

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

. The patient is conscious,  coherent, cooperative 

. Well nourished and Moderately built 

. No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema.

Vitals:

BP: 140/100 mmhg

Pulse rate: 127 bpm 

Respiratory rate: 40 cpm 

SpO2: 97%

GRBS: 128 mg/dl@ admission 

Per Abdomen:

Inspection:- no scars seen.

Palpation:- tenderness in epigastric region.

Percussion:- No free fluid.

Auscultation:- Bowel sounds heard.

SYSTEMIC EXAMINATION :

Respiratory System: 

Upper Respiratory tract examination:

Nostrils- normal 

Nasal septum- no deviation 

No nasal polyps 

No Tonsils 

Posterior pharyngeal wall- normal 

Lower Respiratory tract examination:

Inspection:

Shape of the chest - Circular 

Movement of chest- appears to be equal on both sides

Trachea- appears to be in central position 

Apex beat- visible 

No scars and sinuses seen

Palpation:

Trachea- Central in position 

Apex beat- shifted to left 

Increased vocal fremitus

No rib crowding 

Percussion:

                                     Right                         Left

Supra clavicular         Resonant                 Resonant 

Clavicular                  Resonant                  Resonant 

Infra clavicular           Resonant                 Resonant 

Mammary                  Resonant                  Resonant 

Axillary                      Resonant                 Resonant 

Infra axillary              Resonant                 Resonant 

Supar scapular              Resonant                   Resonant 

Inter Scapular              Resonant                    Resonant

Infra scapular               Resonant.                    Resonant 

Auscultation:

BAE +

Normal vesicular breath sounds 

Inspiratory crepts heard in infrascapular and suprascapular areas

Decreased breath sounds in Infraaxillary area 

No wheeze 

CVS:

S1,S2 heard 

No murmurs 

CNS :

No focal and neurological deficits

HMF -Normal

Pupils- Bilateral PSNL

                      Upper limb                        Lower limb

               Right             Left                  Right          Left

Tone:      Normal        Normal            Normal      Normal

Power:           5/5           5/5                   5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                  +

Plantar         Flexion        Flexion

ECG:

2d echo: 

2d-Echo video

Chest X-ray:

USG Abdomen:

HRCT of Thorax:

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

ANTERIOR WALL MI (Akinetic LAD territory);

HFREF;

PULMONARY TB (Relapse);

RENAL AKI (Non- oliguric)

TREATMENT:

1.INJ LASIX 40 MG IV/BD

2.INJ HYDROCORT 100 mg IV/ BD

3.NEBULIZATION WITH DUOLIN 12th hourly AND BUDICORT 6 th hrly

4.TAB.ECOSPRIN 75 mg PO/OD

5 TAB .CLOPIDOGREL 75 mg PO/OD

6.TAB.ATORVAT 40 mg/PO/OD

7.BP/PR/RR/TEMP CHARTING 2nd HOURLY

8.INFORM SOS