A 70yr old male with breathlessness and dry cough

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

DR JATIN SHARMA 

Roll no. 56

A 70yr old male agriculturer brought to casualty with
C/o dry cough since 4 days
C/o breathlessness since 4 days

HOPI :
A 70 yr. Old male agriculturer  brought to casualty with complaints of dry cough since 4 days, insidious in onset, more during night then daytime, not associated with Sputum, blood tinge, chest pain. H/o seasonal variations present. Not associated with positional variation. Aggravated with fever (if present) and  cold (if present). Relieved with medication.
H/o breathlessness since 4 days, upon walking to some distance(100-200mt.) mmrc grade 2-3, gradually progressive, insidious in onset, more at night compared to day, no seasonal variation since 3 yrs. diurnal variation present, no positional variation. Aggravated on exertion, relieved at rest, orthopnea present, postural nocturnal dyspnea present since 3 yrs.

Past history :
H/o similar complaints in past started from 15yrs.
Dry cough + breathlessness was present, occasionally having seasonal (winters) + diurnal (night >day) variation since 3 yrs.
His breathlessness showed no seasonal variation.
H/o RTA 20 yrs ago, which has lead to deformity in spine ( thoracic scoliosis)
H/o similar complaints in dec, 21 2d echo showed LV hypokinesia, RWMA +, EF - 48%
K/c/o HTN since 1 yr.
No H/o Dm , asthma , TB, epilepsy

Personal history :
Appetite - normal
Diet - mixed
Sleep - normal
Bowel and bladder  movements - normal
Addictions - 1.previously occasional beer drinker, stopped 3 months ago
2. Started smoking beedi/chutta since 17yrs of age stopped 5days ago.

General examination :
Patient is conscious, coherent and cooperative, moderately built and moderately nourished.
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Pedal edema: absent
Vitals:
BP-140/90mmhg
PR- 80
RR- 37bpm
SpO2- 95% on RA in sitting position
100% on supine
GRBS-173mg/dl
Systemic Examination :
CVS- S1S2 ; no murmur heard
RS- BLAE; diffuse ronchi heard
P/A- soft non tender
CNS- HMF intact

Clinical images : 

Investigations : 

    Chest xray PA view 25-12-22

    Chest xray lateral view 25-12-22

    Usg abdomen 25-12-22

    Ecg 25-12-22 

    Abg 25-12-22

    Investigations chart 

Provisional Diagnosis ?COPD - Chronic bronchitis with old MI with Bi fascicular block with k/c/o HTN since 1 yr.

Treatment :
* Inj. Hydrocort 100mg iv stat
* NEB 2 respules duolin, budecort, mucomist every 6th hourly
* inj. Pan 40 mg iv od
* inj. Optineuron 1 amp. In 100 ml NS iv over 30min.
* o2 inhalation @ 2-4 L/min. ( target spo2 - 92%)
* inj. Hydrocort 100mg iv bd
* T.  ASPIRIN(GASTRO-RESISTANT) 75mg
   T. CLOPIDOGRIEL 75mg
   T. ATORVOSTATIN 20mg
* T. Amlong 5mg po od
* monitor vitals 

A 77 year old male with fever, cough and abdominal discomfort

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

DR JATIN SHARMA 

Roll no. 56

77 YR OLD MALE WITH FEVER, COUGH AND ABDOMINAL DISCOMFORT 

 

Date of admission 20-12-22 

C/o fever associated with chills & rigours since 6-7days 

C/o Seizures, 1 episode-3days ago 

C/o cough with Sputum since 2-3 days

C/o abdominal discomfort since 2-3 days

HOPI :

Patient was apparently asymptomatic 6-7days back, then he developed fever of mild to moderate grade, which was insidious in onset, gradually progressive in nature associated with chills, cold, cough with sputum which relieved on medication. Then he had an episode of seizures 4days ago where all 4 limbs were stiff, up rolling of eyes were present, frothing from mouth and passed urine during the seizure episode. He also developed bloating and abdominal discomfort. 

PAST HISTORY:

Patient is a known case of DM since 1 year and he is on medication.

Not a known case of HTN, Asthma,epilepsy,tuberculosis and thyroid abnormalities.

PERSONAL HISTORY:

Sleep: adequate 

Appetite: decreased

Diet: mixed

Bowel and bladder movements: 

Addictions: none 

FAMILY HISTORY:

No similar complaints in the family

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, moderately built and moderately nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: Afebrile 

Pulse: 82 beats/minute

Blood pressure:110/70mm Hg

Respiratory rate: 18 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS- Bilateral air entry present 

B/l infra axillary area and infra scapular area crepts present  

CNS: E4V5M6, higher mental functions intact

P/A- soft ; non tender bowel sounds present, mild splenomegaly present  

CLINICAL IMAGES :-

                                                        

INVESTIGATIONS:

                                           

                  ECG DONE ON 20-12-22  

                 ECG DONE ON 24-12-22

                 2D ECHO DONE ON 21-12-22

                                           

    USG abdomen and pelvis done on 20-12-22

        20-12-22 chest xray PA view 

                                           

           21-12-22 chest xray lateral view 

               23-12-22 chest x ray PA view 

                  Fever chart 

         Hemogram from 22-12-22 to 25-12-22

PROVISIONAL DIAGNOSIS 

pyrexia under evaluation secondary to ? Clinical malaria with renal AKI on ? CKD  with panctopenia secondary to ? hypoprolifrative marrow ? inflammation ?chronic disease with h/o seizures 1 episode 3 days ago secondary to hypoglycemia? with hyponatremia(resolved) with k/c/o type 2 DM since 2 years with acute liver injury 

TREATMENT (updated) 

* Tab doxycycline 100mg PO BD

* IV fluids NS at 100ml/hr

* T. Pantop d po/od 

* Inj. zofer 4mg iv BD

* Inj. Human Act rapid insulin sc. TID

* T. Levipil 500mg po BD

* T. Dolo 650 mg PO BDI 

* Inj. Neomol 1mg iv if temperature is more than 101F

* Vital monitoring   4th hourly 

* GRBS  6 th hourly 

* SYP.  creamaffin 15ml/PO/HS 

* T. Riboflavin 5mg po BD

* oral mucopan gel for L/a

* Neb. Salbutomol 1resp. P/N TID

* plenty of oral fluids