70M Fever and shortness of breath
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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.
70 yrs male resident of velanki , farmer by occupation (not working since two years due to SOB)
Chief complaints :
Fever since 5 days
Dyspnea since 1 day
Reduced urine output since 5 days
HOPI :
Patient was apparently asymptomatic 5 days back then he developed fever which was insidious in onset , progressive , High grade , not associated with chills and rigor, temporarily relieved on medication. He also had difficulty in breathing Grade 2 (Acc to Mmrc ) and progressed to Grade 3. No wheeze, no chest tightness, no haemoptysis, no chest pain or palpitations. He also had complaints of decreased urine output since 5 days
he was referred from pulmonology due to hypotension.
Past history:
H/o cough and sob 4 yrs back and used inhaler ? for a year one and off and got resolved
2 years ago he had similar complaint of severe sob , decreased urine output and generalised weakness and was taken to Nalgonda hospital. about an year ago he had loss of consciousness and was taken to Nalgonda hospital
n/k/c/o dm, htn, hyper or hypothyroidism, asthma, epilepsy, tuberculosis
Family history- insignificant
Personal history:
Diet : Mixed
Appetite : normal
Sleep: Reduced since 5 days
Bowel and bladder: Decreased urine output since 5 days
Habit : Beedi smoking 1 pack per day since 50 yrs and stopped since 1 yr back
Daily routine :
He used to get up at 6 am and freshen up has his tea and breakfast (rice) At 9 am goes to work and works there upto 2:00 pm and has his lunch and then rest for hr and then works upto 6 pm and then returns home and watches TV and has his dinner at 8 pm and then goes to sleep at 9:30 pm
since two years, his daily routine changed in terms of no work because of sob and staying at home all the time just watching tv, eating and taking rest , he is dependent on his sons and also pension money for his daily expenses (food etc)
General examination
Patient was conscious, coherent and co-operative,
clubbing of fingers is seen
Pedal edema is present
No Icterus, Cyanosis, Generalised lymphadenopathy,
Vitals
Temperature - 93
Pulse rate - 113 bpm
Respiratory rate - 22 cpm
BP - 80/50 mm of Hg
SpO2 - 92% at room atmosphere
GRBS - 124 mg/dL
Systemic examination
RS-
Inspection:
urt- poor oral hygiene
shape of chest - bilaterally symmetrical
resonant in all areas
Auscultation:
BAE and VBS present
IAA crepts present
Investigations:
cbp, usg abdomen, chest xray pa view, lft, rft
Provisional diagnosis: acute exacerbation of copd with type - I rf and grade II prostatomegaly
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