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I've 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.
This is a case of 80 year old male with shortness of breath ,right side chest pain,facial puffiness since 3 days.
CHIEF COMPLAINTS:
A 80 year old male patient brought to casualty with
c/o B/L pedal edema since 1 month
SOB since 3 days
right sided chest pain since 3 days
facial puffiness since 3 days
HISTORY OF PRESENTING ILLNESS:
patient was apparently asymptomatic 3 years back then he developed B/L pedal edema which gradually progressed till knee.
SOB - gradually progressed but subsided on sitting.
sob on lying down
Chest pain - non radiating
no H/O nausea, vomiting, sweating
HISTORY OF PAST ILLNESS: k/c/o HTN ,DM from 3 years.
and is on medication for the same.?
TREATMENT HISTORY : In medication for DM - II & HTN.?
PERSONAL HISTORY:
Appetite - normal
Diet - mixed
Bowels- regular
Micturition - normal
Habbits:
Alcohol -(Regular ) ?
Beedi - 3- 4 per day (since 40 years)
FAMILY HISTORY: NOT SIGNIFICANT
GENERALL EXAMINATION:
NO PALLOR,ICTERUS, CYANOSIS ,CLUBBING LYMPHADENOPATHY.
OEDEMA OF FEET +
VITALS:
AT THE TIME OF ADMISSION (17/11/22)
TEMP-98.6 F
PR- 52
BP- 150/80 mm of hg
SPO2 - 97%
GRBS - 12⁹ MG/DL
SYSTEMIC EXAMINATION
CVS:
S1 ,S2 HEARD
JVP - RAISED
NO THRILLS / MURMURS
RESPIRATORY SYSTEM :
TRACHEA - CENTRAL
VESICULAR BREATH SOUNDS
BAE + with wheeze in the left infra scapular and infra axillary area
NO ADVENTITIOUS SOUNDS
PER ABDOMEN:
shape - scaphoid
no tenderness
no palpable masses
no organimegaly
bowel sounds +
CNS - patient is conscious
speech normal
higher mental functions - normal
Motor functions - normal
REFLEXES
BICEPS - ++
TRICEPS -++
SUPINATOR-++
KNEE-++
ANKLE -++
INVESTIGATIONS:
18/11/22
18/11/22 12.20 pm
2D ECHO
19/11/22
Usg
Temperature and vitals monitoring chart
Input/ output
19/11/22
DIAGNOSIS: COPD WITH RIGHT HEART FAILURE
with k/c/o DM ,HTN
? AKI on CKD
18/11/2022
AMC BED NO 1
S:-
80 years old male B/L pedal edema since 1 month , SOB 3 DAYS, Fever 3 days, Rt sided chest pain since 3days
Admitted on 17-11-2022
K/c/o HTN,DM From 3 years on medication
O:-
Patien is conscious, coherent, cooperative
Bp: 140/80
PR:108 bpm
Temp:98.6
Rr:19
CVS:S1 S2 HEARD
RS: BAE +
P/O: SOFT ,NON TENDER
CNS:NFND
A:-
COPD WITH RIGHT HEART FAILURE (CORPULMONALE)
P:-
1 FLUID RESTRICTION < 1-5 lit I day
2 SALT RESTRICTION < 2gm/DAY
3 T LASIX 40MG BD
4 TAB MONTAIR-LC OD
5 NEBULISTATION WITH DUOLIN &BUDECORT 8th hourly
6 TAB PAN 40 MG PO/0D
19/11/22
AMC BED NO 1
S:-
80 years old male B/L pedal edema since 1 month , SOB 3 DAYS, Fever 3 days, Rt sided chest pain since 3days
Admitted on 17-11-2022
K/c/o HTN,DM From 3 years on medication
O:-
Patien is conscious, coherent, cooperative
Bp: 120/70
PR: 62bpm
Temp: 98.6 F
Rr:16
CVS:S1 S2 HEARD
RS: BAE +
P/O: SOFT ,NON TENDER
CNS:NFND
A:-
COPD WITH RIGHT HEART FAILURE (CORPULMONALE)
P:-
1 FLUID RESTRICTION < 1.5 lit I day
2 SALT RESTRICTION < 2gm/DAY
3 T LASIX 40MG po/ BD
4.T.CINOD 10 MG PO/OD
5.TAB MONTAIR-LC PO/OD
6.NEBULISTATION WITH DUOLIN & BUDECORT 8th hourly
