A 75 yr old male came to GM OPD with the cheif complaints of sob,fever,cough since 15 days


This is an a 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


CHEIF COMPLAINT:

A 75 yr old male came to GM OPD with the cheif complaints of sob,fever,cough since 15 days

HOPI:
pt was apparently alright 15 days back then he developed shortness of breath (Grade II) which was insidious in onset

H/O cough not associated with sputum, aggrevated in cold weather,cool drinks

H/O fever since 2 weeks more in morning time relieved on medication

H/O headache, nausea chest pain.

H/O pain in below neck on left side (scapular- region )while lying down

No H/O palpitations, pedal edema, Abdomen distension 

No H/O burning micturition 

No H/O orthopnea

No H/O loss of weight

PAST HISTORY :
H/O  similar complaint in past - 1 year ago

k/c/o HTN 6 yrs on T. AMLODIPINE 5 my OD

DM-II on T. METFORMIN 500mg OD

H/o TB 20yrs , 25yr and used medication 

N/K/C/O Asthma, Epilepsy, CVA, CAD, thyroid disorder

FAMILY HISTORY:

No similar complaints are present in family members

PERSONAL HISTORY :

Diet: mixed 

Appetite- normal

Sleep- adequate

Bladder movements- Regular

Bowel movements- Regular 


GENERAL EXAMINATION AT ADMISSION 

Patient is conscious, coherent and cooperative. Well oriented to time,place and person,well built and nourished

Pallor-absent

Icterus-absent 

Cyanosis-absent

Clubbing-absent

Lymphadenopathy -absent

Edema-absent 

VITALS ON ADMISSION

BP -120/70mmhg

PR-72bpm

RR- 20cpm

TEMP- Afebrile

SPO2- 100 @room air

GRBS-102mg/dl

SYSTEMIC EXAMINATION

 R/S -

INSPECTION

Position of trachea-central 

shape of chest - Elliptical

chest -Asymmetrical

TACTILE FREMITUS - R.L.

Increased on right side compared to left side

PERCUSSION - R.L.

-dullness on rt side compared to left side

Auscultation:

Crackles heard on left side 
Normal sounds on left side

CVS:s1, s2 heard ,no murmurs.

P/A : Soft, non tender, no organomegaly

CNS:
Higher motor functions - intact
Cranial nerves - intact
Motor system:

     Rt- UL. LL. Lt- UL. LL

Bulk - N N. N. N 

Tone - N. N. N. N

Power - 5/5. 5/5. 5/5. 5/5

Reflexes:                                

                    UL LL

Biceps. 2+. 2+

Triceps. 2+. 2+

Supinator. 2+. 2+

Knee. 2+. 2+

Ankle. 2+. 2+

Sensory system: intact

Co ordination is present


✓DROOPING OF RIGHT SHOULDER 




INVESTIGATIONS:

Random blood sugar-101 mg/dl

Glycated hemoglobin- 6.5%

Fasting blood sugar-96 mg/dl

Hemogram-


RFT-


LFT-


CUE-


Chest X ray (PA view) -


HR CT lung video link:
1.

https://youtube.com/shorts/T9JRuNxpiec?si=rd5ecbgaDoCtPUry

2.

https://youtu.be/IP8dgUMNX_A?si=1ugsnUFM8jEABeVh



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