A 84 year old male with shortness of breath

6th Dec 2022

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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. 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. 

A 84 yr old male resident of nakrekal , farmer by occupation presented  to the OPD with complaints of 

Difficulty in breathing since 1 month 

Cough with sputum since 9 days 

Pain in the left side of lower abdomen while coughing since 3 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4 yrs back , then he developed swelling in the right leg which was diagnosed as filariasis for which he did not use any medication 

3 yrs ago he had h/o trauma to the left leg which was operated

Recent complaint of the patient since 1 month is shortness of breath which was insidious in onset , gradually progressive in nature , which aggravated on walking and since 7 days it is not relieved on sitting and lying down and no seasonal variation 

H/o decrease in urine output since 20 days for which urethral stricture dilatation was done 

Patient complained of pain in the left lower abdomen since 3days which is of throbbing type. Which is gradual in onset, no aggrevating and releving factors.

No h/o fever , weight loss , burning micturition,orthopnea,palpitations, nausea and vomiting.

NO h/o trauma, fever, loss of appetite, constipation 

PAST HISTORY

Not a known case of diabetes , hypertension , asthma , epilepsy , tuberculosis, coronary artery disease.

H/o previous surgery ( rod and plate fixation ) for trauma of left leg 

PERSONAL HISTORY 

He is an elderly male who was farmer by occupation but stopped work since 15 yrs . 

His daily routine is as follows 

He wakes up at 6 in the morning and does his daily routine, he limited his physical activity due to his condition and age.

Appetite:decreased 

Diet:mixed 

Sleep:adequate 

Bladder movements: decreased 

Bowel movements: regular 

Addictions:smoking in the past but stopped 15 yrs ago 

                     Alcohol drinking in the past stopped 1 yr ago 

FAMILY HISTORY 

No significant family history

GENERAL EXAMINATION

Patient is conscious,coherent,cooperative and well oriented to time,place and person 

He is well built and moderately nourished 

Pallor - present 

Bilateral edema present of grade 3 which is pitting type 

No signs of icterus , cyanosis , clubbing , lymphadenopathy 

VITALS :

Temperature -98.6 F

Pulse rate-70bpm

Blood pressure :110/80mm.hg

Respiratory rate :20 cpm

Spo2-96 % room air 

SYSTEMIC EXAMINATION

CVS:

Inspection:

No visible heart pulsations

Palpation:

Apex beat at 6th intercoastal space

Auscultation: 

S1,s2 are heard

Rhythm regularly irregular

RESPIRATORY SYSTEM 

Inspection: 

Chest shape normal

Breath movements -abdominal thoracic

 Dysponea - present

Palpation:

 Trachea -central

Percussion: 

Dull note in infra axillary and infra scapular regions

Auscultation: 

Coarse basal crepitations are heard

In infra axillary and infra scapular area

 Wheezing heard in mammary region

Vesicular breath sounds.

ABDOMINAL EXAMINATION 

Shape - scaphoid

Tenderness - no

Free fluid - no

Liver - not palpable

Spleen- not palpable

CNS: 

No focal neurological deficits 

INVESTIGATIONS

30/11/22

1/12/22

2/12/22

3/12/22

4/12/22

 

X RAY 

5/12/22

PROVISIONAL DIAGNOSIS

Dilated cardiomyopathy 

Bilateral syn pneumonic effusion

With right leg filariasis ( 4yrs back)

Intramuscular abscess over left Iliac fossa.

TREATMENT 

Inj. Augmentin, 1.2 gm, IV, TID

Tab. Azithra, 500 mg, OD, Per oral

Tab. Pantop, 40 mg, OD, per oral

Tab. Met xl, 25 mg, OD, per oral

Tab. Montair LC, per oral

Tab. Ecospirin, 75 mg

Abscess is drained with 10cc and 20cc syringes(pus is not present).