80yr male with SOB
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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
A 80 year old male who was patient agricultural labourer by occupation was bought to the casualty with the
CHEIF COMPLAINTS of
Fever since 8 days
Shortness of breath since 1day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 8 days and developed fever which was high grade, intermittent in nature associated with chills and relieved on medication.patient went to local hospital and diagnosed with dengue (NS1+ve) and got admitted for 5 days also had a history of cough since 5 days wet cough, whitish sputum, non blood tingled , Breathlessness since 1 day , insidious in onset gradually progressive from grade 2 to grade 4 not associated with excessive sweating/ nausea
HISTORY OF PAST ILLNESS:
Know case of Hypertension since 1year ( Tab. Atenolol 50mg )
Not a known case of DM,TB,CAD,Epilepsy
TREATMENT HISTORY :
For Hypertension from 1 year Tab. Atenolol 50mg
FAMILY HISTORY:
His brothers had similar history and passed away
PERSONAL HISTORY
DIET: Mixed.
APPETITE: Normal
SLEEP: Adequate
BOWEL AND BLADDER MOVEMENTS: Regular
Addictions :
Tobacco -He smokes 1 pack of bidi per day daily . Alcohol - Occasionally
GENERAL EXAMINATION:
patient is conscious, coherent , co operative.
Moderately built and moderately nourished
No Pallor, Icterus, Clubbing, Cyanosis, Lymphadenopathy, Edema.
AFEBRILE
BP- 110/80 mm hg
PR- 89bpm
RR- 24cpm
SpO2- 97% at room air
GRBS -117mg/dl
Per Abdomen:
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM :-
INSPECTION:
Upper respiratory tract-
Oral hygiene maintained
No oral thrush
No Post nasal drip
Dental caries -absent
No deviation of Nasal septum
No nasal polyps
Lower respiratory tract:
Barrel shaped chest
Tracheal position is central
Symmetrical chest
Apical impulse: not seen
Movements of chest :
Respiratory rate: 22 cpm
Type :Abdominothorax type
Symmetry : Bilateral equal
Accessory muscles used
Skin over chest : no engorged veins , subcutaneous nodules , intercostal
Trails sign : trachea is central placed Remaining areas are normal
scars, intercostal swelling is seen
PALPATION:
All inspectory findings are confirmed by palpation No local rise in temperature
No tenderness is seen
Trachea is central
Chest is symmetrical and expanded
Symmetrical expansion of chest .
Dimensions
Circumference: Rt / Lt 1. Transverse :
2. Anterioposterior :
3. Hemi thorax :
Tactile vocal fremitus: decreased
PERCUSSION:
Hyper Resonant on chest percussion.
AUSCULTATION :
Wheeze heard during expiration
Normal breath sounds decreased
CVS:
S1,S2 heard
No murmurs
CNS:
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
INVESTIGATIONS:
CHEST X-RAY:
PROVISIONAL DIAGNOSIS:
Acute Exacerbation of COPD (Chronic Bronchitis) secondary to LRRI ?Viral
Dengue (NS1 +) with Thrombocytopenia ;
Acute Liver injury secondary to Viral illness
TREATMENT:
IV Fluids (NS,RL)@ 100ml/hr
INJ. Thiamine 200mcg in 100ml NS IV/BD over 1hr
Nebulisation with BUDECORT 12hrly and DUOLIN 8hrly
INJ. NEOMOL 1gm IV/SOS
TAB. DOLO 650mg PO/SOS
TAB. AMLOKIND AT PO/OD
TAB. PULMOCLEAR 150mg PO/OD
TAB. MVT PO/OD
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