65 YEAR OLD MALE WITH SHORTNESS OF BREATH

 Kausalya Varma, Intern 

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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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 diagnosis and treatment plan. 



AN 65 YEAR OLD MALE BROUGHT TO THE HOSPITAL WITH SHORTNESS OF BREATH FOR ONE WEEK 


CASE:


CHIEF COMPLAINTS: 


A 65 year old male patient came with the complaints of shortness of breath for the past 1 week, cough, fever and decreased urine output for the past 3 days. 

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 1 week back when he developed shortness of breath grade 2, which was relieved on taking rest. 
- He then developed cough which was productive in nature, whitish coloured sputum, not associated with blood.
- He has fever since the past 3 days which is high grade, associated with chills and which was insidious in onset, intermittent, high grade, decreasing on taking medications, had no aggravating factors and what evening rise of temperature. 

- He has a history of decreased urine output for the past 3 days.

- No H/O weight loss or loss of appetite since the past 3 days.

- No H/O chest pain, palpitations and sweating 

- No H/O pedal Edema, burning micturition or frothy urine.



PAST HISTORY-

- No similar episodes in the past. 
- Patient is a k/c/o DM type 2 since 1 week and has been put on Glimi M1.
- Not a known case of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD. 

PERSONAL HISTORY- 

Occupation: Agricultural labourer
Diet: Mixed 
Appetite: Decreased for the past 1 week 
Sleep: Normal 
Bowel and Bladder: Regular
No allergies 
Takes alcohol/toddy occasionally (only on festivals) 
Is a known smoker and usually smokes into 5-6 bidi/day 

FAMILY HISTORY- 

No similar history in family.

GENERAL EXAMINATION- 

Patient is examined in a well lit room after taking informed consent. 
Patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 

Pallor: Absent 
Icterus: Absent 
Cyanosis: Absent 
Clubbing: Absent 
Generalized Lymphadenopathy: Absent 
Edema: Absent
Dehydration: Mild 








VITALS
Blood Pressure: 110/70 mmHg
Respiratory Rate: 19 cycles per minute
Pulse: 106 bpm
GRBS- 540mg%

Temperature: Afebrile



SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM-  


Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen


Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 


Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.


Auscultation-

Wheeze heard in bilateral infrascapular areas 





CARDIOVASCULAR SYSTEM- 


Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 


Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 


Percussion- 

Right and left borders of the heart are percussed 


Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.

PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.

PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.

AUSCULTATION:
Bowel sounds are heard.


CENTRAL NERVOUS SYSTEM-


HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.


All cranial nerves - Intact


Motor system

                              Right.                  Left


BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N


TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N


POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5



Superficial reflexes and deep reflexes are present, normal

Gait- Normal 

No involuntary movements


Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated



INVESTIGATIONS : 

26/12/22

HEMOGRAM

Hemoglobin: 11.7
TLC: 10,200
Platelet: 2.56
PCV: 34.6
RBC COUNT: 3.93

ELECTROLYTES
Na: 140
Cl: 100
K: 3.8
Mg: 2.0

RBS- 599


RENAL FUNCTION TESTS
Urea: 112
Creatinine: 2.0
Uric Acid: 7.9

LIVER FUNCTION TESTS
Total Bilirubin: 1.81
Direct Bilirubin: 0.38
SGPT: 73
SGOT: 88
ALP: 1098
Total Protein: 5.9
Albumin: 2.72
A/G: 0.86

27/12/22

HEMOGRAM

Hemoglobin: 11.7
TLC: 10,200
Platelet: 2.56
PCV: 34.6
RBC COUNT: 3.93

ELECTROLYTES
Na: 123
Cl: 98
K: 3.8


RBS- 599


RENAL FUNCTION TESTS
Urea: 112
Creatinine: 2.0
Uric Acid: 7.9

LIVER FUNCTION TESTS
Total Bilirubin: 1.81
Direct Bilirubin: 0.38
SGPT: 73
SGOT: 88
ALP: 1098
Total Protein: 5.9
Albumin: 2.72
A/G: 0.86

28/12/22

HEMOGRAM

Hemoglobin: 12.2
TLC: 34,000
Platelet: 1.99
PCV: 35.8

ELECTROLYTES
Na: 130
Cl: 101
K: 3.5


RENAL FUNCTION TESTS
Urea: 94
Creatinine: 1.4

LIVER FUNCTION TESTS
Total Bilirubin: 0.74
Direct Bilirubin: 0.18
SGPT: 28
SGOT: 49
ALP: 607
Total Protein: 6.2
Albumin: 2.9
A/G: 0.86

29/12/22

HEMOGRAM

Hemoglobin: 12.1
TLC: 20,500
Platelet: 1.99
PCV: 34.8

ELECTROLYTES
Na: 129
Cl: 98
K: 3.4


RENAL FUNCTION TESTS
Urea: 38
Creatinine: 1.0

LIVER FUNCTION TESTS
Total Bilirubin: 0.63
Direct Bilirubin: 0.20
SGPT: 15
SGOT: 40
ALP: 494
Total Protein: 5.7
Albumin: 2.6
A/G: 0.86

30/12/22

HEMOGRAM

Hemoglobin: 12.5
TLC: 15,100
Platelet: 2.23
PCV: 36.5

ELECTROLYTES
Na: 131
Cl: 98
K: 3.5


RENAL FUNCTION TESTS
Urea: 61
Creatinine: 1.2

ECG- 

26/12/22



27/12/22



FEVER CHART 



PROVISIONAL DIAGNOSIS-


Acute exacerbation of COPD with left upper lobe consolidation with cavitations (?infective) with uncontrolled sugars

Denovo DM detected 5 days back 




TREATMENT- 


28/12/22

O2 supplementation if spO2 <90%

Head end elevation up to 30degrees

IV fluids NS,RL @75ml/hr

Inj NPH SC/BD/ pre meal 

Inj HAI SC/TID/ pre meal 

Inj Augmentin 1.2g IV BD 

Inj PAN 40mg IV OD

Tab DOLO 650mg PO TID 

Syp ascoril LS 15ml PO TID

GRBS 7 point monitoring and inform 

Tab MUCINAC 600mg PO BD with a glass of water 

Nebulisation Duolin and Budecort 8th hourly 

Monitor vitals and inform SOS 

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