A 67 year old male barber came with chief complaints of SOB, FEVER, PAIN ABDOMEN
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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.
AMC CUBICAL 2
DOA:04/06/23
A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of
Shortness of breath since 1 week
Fever since 4 days
Pain in the left lower abdomen since 4 days
HOPI :
Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2 initially aggravating on doing work, walking and then progressed to grade 4 (SOB even at rest) , no aggravating and reliving factors, no orthopnea, PND.
He also had fever since 4 days insidious in onset, gradually proggresive, high grade type, evening raise temperature associated with chills and rigors relieved by medication and increases again after the effect.
H/O pain abdomen in the left iliac and lumbar region since 4 days which was insidious in onset, gradually proggresive, squeezing type, non radiating, no aggravating and reliving factors
C/o decrease in appetite since 4 days, weakness.
H/O Vomitings 3 days back 2-3 episodes, watery along with food particles, non-projectile, non- blood stained, non foul smelling, non biliary.
H/O loose stools 2-3 episodes 3 days back which watery , non-mucoid , non blood stained , non foul smelling
For these complaints he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to KIMS, narketpally hospital.
No c/o of chest pain , palpitations
PAST HISTORY :
He had history of hypertension since 10 years and on medication( TAB Olmesartan -H) but stopped since 6 months
No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA .
History of previous surgery Renal stunting 6 months back.
PERSONEL HISTORY:
Mixed diet
Sleep - Decreased
Appetite: Decreased appetite since
Bladder - decreased urine output with burning micturition since 10 years
Bowel movements are regular ( 2 episodes of loose stools 3 days ago )
Addictions : he started taking chewable tobacco since 30 years and stopped one week back
He also had a history of taking alcohol since 25 years and stopped 6 months back
Family history: Not significant
Treatment history :
tab Olmasartan since 10 years stopped 1 month ago
Renal Stenting 6 months back
5 years ago he had knee pains and went to
General examination :
Patient is conscious, coherent , cooperative
He is well built and moderately nourish
Pallor absent
No Icterus, clubbing, Cyanosis, Lymphadenopathy, Edema.
VITALS:
TEMP:97.2F
PR:117bpm
RR:28cpm
BP:120/80
Spo2: 94% @4L O2
GRBS:128mg/dl
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appear normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 5th Intercoastal space
No dilated veins,sinuses, visible pulsations.
Palpation:-
No local rise of temperature
No tenderness
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
Chest movements : equal on both sides
Vocal fremitus same on both sides in all areas
Percussion -
Resonant in all areas on both sides
Auscultation -
BAE +ve
NVBS on both sides
Vocal resonance same on both sides
ABDOMEN:
Shape - Scaphoid
No tenderness, palpable mass, No Fluid
No bruits
Liver not palpable
Spleen not palpable
Bowel sounds heard
CVS:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
Palpation :
Apex beat can be palpable in 5th inter costal space
Auscultation :
S1,S2 are heard
no murmurs
CNS Examination:
Pt is Conscious ,coherent, cooperative
Speech normal
Cranial nerves, motor system, sensory system Normal
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
TREATMENT:
1.INJ LASIX 40 MG IV STAT
2.NEB WITH DUOLIN STAT BUDECORT
3.INJ NEOMOL 1GM IV SOS
4.TAB DOLO 650MG PO/BD
5.TAB OLMESARTAN-H PO/BD
6.BP,PR,TEMP CHARTING 4 th HOURLY.
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