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

 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 PRESENTING ILLNESS

Patient was apparently asymptomatic 2 months back Then he developed cough which was thick,whitish, productive ,non blood tinged since 2 months and aggravated since 15 days

Now since 15 days he developed fever which was intermittent, High grade , nocturnal variation and relieved on medication 

Complaints of chest pain (left sided,localised, heaviness) since 4pm on 23/6/2023

Chest pain is not associated with palpitations,SOaB,orthopnea,PND

No H/o weight loss,night sweats,pain abdomen,

burning micturition,cold,vomiting,loose stools

PAST HISTORY

H/o outside hospital admission for the similar complaints on 11/6 /2023 to 16/6/2023

Inj.MONOCEF was given

H/o CAD 8 yrs ago PTCA  was done and 3 yrs ago repeat history of CAD but was managed conservatively with thrombolytics

K/c/o HTN since 8 yrs on regular medication(Amlodipine)

Not a known case of CVA,DM,Asthma,TB, Epilepsy,thyroid disorders

PERSONAL HISTORY

Diet: Mixed
Sleep: Adequate 
Bowel and bladder movements: Regular 
Addictions: alcoholic since 40 yrs 90 ml/day stopped 20 days back
Smoker since 40 yrs 1 beedi packet/day stopped 20 days back 

FAMILY HISTORY
Not significant. 

GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Poorly Built & nourished
Pallor present
No Icterus 
No cyanosis
No clubbing
No edema
No lymphadenopathy.
Vitals
Temp 103.8
BP 110/70 mm Hg
PR 90 bpm
RR 24 cpm
GRBS 106 mg/dl

SYSTEMIC EXAMINATION
RS 
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 
Shape of chest - normal
Chest movements : equal on both sides
Trachea appears central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
AUSCULTATION 
BAE+,  NVBS
CVS
Inspection
Shape of the chest Bilaterally symmetrical
No engorged veins,scars, visible pulsations
Jvp is not raised
Palpation
Apex beat felt in 5 the intercostal space medial to mid calvicular line
No thrills
Auscultation
S1 S2 Heard
No murmurs
Per abdomen

 :soft and non tender,No organomegaly

CNS:NFND







INVESTIGATIONS
























DIAGNOSIS
Pyrexia under evaluation 
?Viral bronchitis ? COPD with Anemia under evaluation (NC/NC)
TREATMENT
IV fluids 1 NS @ 50ml/hr
                  1 RL 
Inj.OPTINEURON 1 amp in 100 ml NS IV/OD
Inj.Neomol 1 gm IV/sos if Temp greater than101 F
Tab.DOLO 650 mg po/sos
Tab.ECOSPRIN-AV (75/10) po/HS
Tab.NICORANDIL 5 mg PO/OD
Tab.NTG 2.6 mg po/o
OD
NEB Ipravent 8 th hrly
          Budecort 8 th hrly




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

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