60 yr old male with lower back ache and shortness of breath












 A 60 yr old male resident of daily wage labourer  by occupation came with chief complaints of lower back ache since 10 days and shortness of breath since 5 days 

HISTORY OF PRESENTING ILLNESS 

Pt was apparently asymptomatic 6 months back the he developed sudden onset of chest pain with high blood pressure and was diagnosed with MI and PTCA was done .

Now since 5 days she developed sudden onset of chest pain and shortness of breath

Chest pain is retrosternal,non radiating

Shortness of breath since 5 days grade ll to grade lll ,

PAST HISTORY

K/c/o DM since 10 years 

PERSONAL HISTORY

Diet  mixed

Appetite Normal

Sleep  adequate

Bowel and bladder Regular

Addictions alcoholic since 20 yrs 70ml/day and smoker since 20 yrs 2 chutta/day 

GENERAL EXAMINATION

Patient is conscious coherent and cooperative

Moderately built and nourished

No pallor, Icterus, cyanosis, generalized lymphadenopathy,edema 

Mild clubbing is present

Vitals 

Temp Afebrile

Bp 130/70 mm Hg 

PR 82 bpm 

RR 18 cpm 

GRBS 106 mg/dl 

Systemic Examination

CVS S1 S2 Heard no murmurs

RS BAE + NVBS heard

P/A soft and non tender

CNS No focal neurological deficit

INVESTIGATIONS

DIAGNOSIS

Lower back ache under evaluation 

Treatment

Tab.GLIMI-M PO/OD

Tab.ECOSPRIN 150 mg+ Tab.ATORVASTATIN 40 mg PO/HS

Tab.PAN 40 mg PO/OD

Tab.ULTRACET 1/2 tab/QID













Comments

Post a Comment

Popular posts from this blog

A 22 yr old female with generalized weakness and easy fatiguability since 2 months

Image
 A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months  History of Presenting illness Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done Now since 2 months she is complaining of easy fatiguability with generalized weakness  C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III,c/o exertional dyspnea  No c/o chest pain, palpitations, orthopnea,pnd  No c/o fever,loose stools, vomitings PAST HISTORY H/o similar complaints in the past H/o two PRBC transfusion N/k/c/o diabetes HTN TB Asthma Epilepsy thyroid disorders  PERSONAL HISTORY Diet  Mixed Appetite normal Sleep adequate Bowel and bladder  regular Addictions No  Daily routine  Pt wakes up around 7 am takes breakfast and goes for coaching...
Read more

65 year old male with cough since 2 months and fever since 15 days and chest pain since 1 day

Image
 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome. I've 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. A 65 year old male resident of chityal labourer by occupation came with chief complaints of fever, cough with sputum since 15 days and chest pain from  4pm of  23/06/2023 HISTORY OF PRE...
Read more

A 45 year old female patient presented with chief complaints of fever and shortness of breath

Image
 A 45 year old female patient resident of Chinthapally who is a agricultural labourer by occupation came with chief complaints of shortness of breath and fever since 15 days  HOPI  Patient was apparently asymptomatic 15 days back. Then she developed fever since 15 days associated with chills .She also has shortness of breath since 15 days. 15 days ago she had fever for which she went to the local hospital and got treated. After the treatment the fever subsided and she developed fever again for  which she went to the local hospital where she was diagnosed with thrombocytopenia.Then they came to Kims 3 days ago for the treatment of thrombocytopenia. No history of nausea vomiting. Past history :No history of Hypertension, tuberculosis, asthma. Personal history Diet:mixed  appetite : normal Bowel and bladder: regular Sleep : adequate Addictions:no addiction Family history:no relevant family history General examination: Patient is conscious, coherent and non-cooperat...
Read more