67/M WITH SOB AND FEVER

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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.

UNIT 1 

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 4-5 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

Treatment history: 

Renal Stenting 6 months back

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 Daignosis: 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.