A 78 yr old male with 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. 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 78 yr old male patient,resident of nakrekal,farmer by occupation presented with chief complaints of 

SHORTNESS OF BREATH since 1 month

Which aggravated  since 1 day 

COUGH since 4 days 

HISTORY OF PRESENTING ILLNESS:

pt was apparently asymptomatic 4 yrs ago 

Then he developed swelling in right leg which was  diagnosed as filariasis .no medication was taken for this condition.

3 yrs back pt had a trauma to left leg and was operated (rod and plate fixation done)

Since 1 month pt complains of shortness of breath (grade 3) which was insidious in onset gradual in progression aggravated on walking and no seasonal variation.

15days back patient had decreased urinary out put for which urethral stiture dialation done one week back 

 

H/o cough since 4 days 

H/o orthopnea since 3 days

H/o weight loss from 2 week

 No h/o fever,burning micurition

 H/ourgency to urination, increased frequency of urination.

No H/o adequate sleep

6months back he had localized biilateral swelling on legs

Exertional sob

Past HISTORY:

He has no history of  hypertension, diabetes 

,asthma, epilepsy, tuberculosis. 

H/o trauma in left leg after he fell due to loss of consciousness after getting fever

Treated by internal fixtures

H/o right leg swelling due to filariasis

No previous hospitalizations

PERSONAL HISTORY:

He is an elderly male who was previously a farmer but not doing any work from past 15 years .In home he gets up at 6 ,do his daily routine activities and sit quietly.

Apettite-decreased

Diet- mixed

Bladder- decreased

Bowel -normal

Sleep-disturbed 

Addictions- Smoking-stopped 15 years ago

Alchol-stopped 1yr ago

Family history: Not significant

GENERAL PHYSICAL EXAMINATION 

 

Pt is consious,coherent,cooperative and well oriented to time,place and person 

He is well built and moderately nourished

Pallor present

 bilateral peadal edema(pitting type)

No icterus,cyanosis, clubbing 

VITALS: 

Temperature -98.6 F

Pulse rate-80 bpm

Blood pressure in sitting position:

130/90mm.hg

Respiratory rate :20 cpm

Spo2-96 %

SYSTEMIC EXAMINATION

CVS

on 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: 

ECG:

USG:

Chest X-ray :

PROVISIONAL DIAGNOSIS:

Heart failure(?) 

COPD(?)

B/L pleural effusion 

Post renal AKI