65year male with lower abdominal pain and 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

            

65year old male patient , was a farmer by occupation(stopped 6 yrs ago) , who is resident of chotuppal came to medicine OPD with,

CHEIF COMPLAINTS:

Lower abdominal pain for 7 days

Shortness of breath for 7 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 25 years back then he had a cough that was blood-stained when he was diagnosed with Tuberculosis ( by what test??) and was on ATT for 6 months after he was said that he is free from the disease.

Then 2 years back then he started having shortness of breath Grade 2 ( sob on some physical activity) which is insidious in onset and relieved temporarily on medication ( drug - unknown; dose unknown; indication - unknown ) from then he had intermittent shortness of breath which relieved on the medication temporarily. 

6 months back he again developed shortness of breath of grade 2 ( walking after 300 m ) which is insidious in onset where he was taken to a higher center where he was prescribed a medication that he didn’t use properly and used only on the aggravation of shortness of breath.

After that 5 months back he suffered from an accident where his left tibia and left rib ( which rib???) got fractured where he was managed with POP casting for 45 days and on calcium tablets ( dose -500mg).7 days back He also experienced diffuse pain all over the abdomen which was insidious in onset and was not radiating and relieved on temporary medication ( drug - unknown; dose unknown; indication - unknown ) character of pain (?)

NO H/O of Hematemesis, Malena, Vomiting, Nausea H/O bulky stools, black tarry, and clay-coloured. H/O Jaundice, pruritus

NO H/O fever with chills

NO H/O anorexia

NO H/O orthopnea, palpitations

NO H/O frothy urine

NO H/O haematuria, oliguria

NO H/O blood transfusions

NO H/O tattoo marking

NO H/O loss of weight

He also developed shortness of breath for 7 days which was insidious in onset grade 3 ( sob on normal physical activity) which was relieved on medication ( drug unknown; dose - unknown) 

There is a history of cough which is productive ( which has mucous as content scanty in quantity; white in colour; and no foreign bodies) fatigue; sweating ; 

No history of palpitations 

No H/O fever, or joint pains. 

PAST HISTORY:

History of pulmonary TB 25 yrs back 

No history of DM ,Hypertension, asthma, epilepsy.

No history of prolonged hospital stay

No history of previous surgeries

PERSONAL HISTORY:

Appetite - Reduced since 1 year

Diet - Mixed

Bowel and Bladder - Regular

Sleep - inadequate 

Addictions - stopped 20 years back, before alcohol and smoking

FAMILY HISTORY:

None of the patient’s parents, siblings, or first-degree relatives have or have had similar complaints or any significant co-morbidities.

ALLERGY HISTORY:

No allergies to any kind of food or medication.

Asthma/COPD/ CAD/ Blood transfusions

Any surgeries, drug usage, allergies.

HIGH ARCHED PALATE

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative comfortably seated/lying on the bed, well-oriented to time,place and person , moderately build and nourished

Pallor present, 

No, Icterus, cyanosis, clubbing ,generalized lymphadenopathy and no pedal edema 

Pulse: Rate:106, rhythm(regular)character(normal ), volume :- low 

peripheral pulsations [Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis]- present 

no radio radial delay 

BP: 120/80 mm Hg measured on Rt Upper arm In supine position

Respiratory Rate:25 cpm

Temp: afebrile

Spo2:99

RESPIRATORY SYSTEM:

INSPECTION:

1. Shape of Chest - normal

2. Trachea position central

3. Apical Impulse - no visible

4. Movements of the chest: Respiratory rate:- 14cpm Type- abdomino thoracic type no accessory muscles involved.

5. Skin over the chest: Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.

6. All the areas appear normal.

PALPITATION:

1. No local rise in Temperature and tenderness

2. All inspector findings confirmed. (Tracheal position, apex beat)

3. Expansion of the chest- equal in all planes 

PERCUSSION:

Resonant all over the chest except infraxillary area

AUSCULTATION:

1. Normal breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.

GASTROINTESTINAL SYSTEM :

INSPECTION:

9 REGIONS

Shape (scaphoid)

No Distention of Abdomen 

Flanks- full 

Umbilicus- normal 

The skin over the abdomen: (smooth)

No engorged veins, visible pulsations, or hernia orifices.

PALPATION:

No tenderness .

No hepatomegaly and splenomegaly

PERCUSSION:

Normal

AUSCULTATION:

1. Bowel Sounds - heard 

CARDIOVASCULAR SYSTEM:

INSPECTION:-

Appears normal in shape

Apex beat is not visible

PALPATION:

1- All inspector findings were confirmed.

2-Trachea is central.

3-Apex Beat - diffuse 

No palpable murmurs (thrills)

AUSCULTATION:-

S 1; S 2 heard in all the areas

INVESTIGATIONS:

29/11/22:

30/11/22:

1/12/22:

2/12/22:

3/12/22:

4/12/22:

PROVISIONAL DIAGNOSIS:

Cor Pulmonale Heart failure ( mid range preserved ejection fraction EF 52%) With anemia under evaluation With Chronic Kidney disease (heart failure and cystic kidney disease) With history of pulmonary tuberculosis 25 years ago.

TREATMENT: 

Head end elevation up to 30 degrees

supplementation if spo2<90%

MONITOR 4- hrly

NEB - SALBUTAMOL 4 hrly

FEVER CHART 4 th hrly 

InJ LASIX 4O mg