67/M WITH SOB AND FEVER

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.

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 4-5 days


HOPI :


Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which 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 our hospital.


He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again.


H/O decreased urine output since 6 months


C/o pain abdomen on &off left lumbar region since one week


C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents


C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling


C/o decrease in appetite since 1 week 


No c/o of chest pain , palpitations 


PAST HISTORY


He had history of hypertension since 10 years and on medication 


TAB Olmesartan -H


No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 


History of previous surgery Renal stunting 6 months back


PERSONEL HISTORY: 

Diet:mixed

Sleep:regular 

Appetite: decreased appetite since 1 month 

Bladder - decreased urine output with burning micturation since 1 month

Bowel movements are regular 

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 one year back

Family history: Not significant


General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 


He is well built and moderately nourish


Pallor present 




Icterus: Absent 


Cyanosis: Absent 


Clubbing: Absent 


Lymphadenopathy: absent 


VITALS:


TEMP:97.2F


PR:117bpm


RR:28cpm


BP:120/80


Spo2: 94% @4L 02


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:-

All inspiratory findings confirmed


Trachea central in position


Apical impulse in left 5th ICS, 1cm medial to mid clavicular line


Infraclavicular- (NVBS) (NVBS)


Mammary- (NVBS) (NVBS)


Axillary- (NVBS) (NVBS)


Infra axillary-(NVBS) (NVBS)                 


Suprascapular- (NVBS) (NVBS)


Interscapular- (NVBS) (NVBS)


Infrascapular- (NVBS)(NVBS)


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



PER ABDOMEN:-






Shape of abdomen-scaphoid

Tenderness-No

Palpable mass-No

Liver- Not palpable

Spleen - Not palpable

Bowel sounds - Normal




Provisional Diagnosis: left hydroneprosis secondary to ? left ureteric obstruction ? Post renal AKI

Investigations:- 









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 4TH HOURLY.




Treatment:-


1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg



11/6/23

Vitals:-


Temperature : 101 F


Pulse rate : 96 bpm


Blood pressure: 120/70mm Hg


Treatment:

1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg


12/6/23


Treatment:-

1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 mg


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg





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