80 Y/O M WITH SHORTNESS OF BREATH AND EPIGASTRIC PAIN

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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.

An 80 year old male from orangudam, farmer by occupation, came to the OPD with chief complaints of shortness of breath since 1 year, epigastric pain and discomfort after eating food since 6 months, diminished vision in both eyes since 1 year and bilateral knee pain since 2 years.

History of presenting illness

Patient was apparently asymptomatic 1 year ago and then he developed shortness of breath, insidious in onset and gradually progressed from grade I to grade II. No paroxysmal nocturnal dyspnoea, no orthopnea, no diurnal and seasonal variations. Epigastric pain and discomfort after eating food since 6 months and especially after eating spicy food.

History of past illness

k/c/o hypertension since 10 years and on medication since 1 year)

n/k/c/o diabetes mellitus, hyper or hypothyroidism, asthma, CAD, epilepsy and tuberculosis.

Family history 

not significant 

Personal history

appetite is normal

bowel and bladder movements are regular

no known allergies

habit of alcohol consumption once monthly occasionally since 10 years.

no habit of tobacco use

General examination

Patient was conscious, coherent and co-operative, 

No Icterus, Cyanosis, Koilonychia, Generalised lymphadenopathy, Pedal edema.

Vitals

Temperature - Afebrile 

Pulse rate - 98 bpm

Respiratory rate - 18 cpm

BP - 190/100 mm of Hg

SpO2 - 98% at room atmosphere 

GRBS - 148 mg/dL

Systemic examination

 cvs - 

no thrills, 

no cardiac murmurs, 

S1 and S2 sounds heard

 rs -

 dyspnoea is present, 

position of trachea is central,

 no wheeze, 

vesicular breath sounds present  

abdomen - 

scaphoid in shape, 

no tenderness, 

no palpable mass, 

hernial orifices are normal,

 no bruits or free fluid,

 liver and spleen are not palpable, 

bowel sounds are present. 

cns -

conscious 

speech is normal

no neck stiffness, no kerning's sign 

cranial nerves, motor system, sensory system are all intact and normal.

reflexes -

                        RT.            LT

biceps      2p.                2p

triceps        2p                2p

supinator     1+              1+

knee          2p.               2p

ankle          1+                 1+ 

cerebellar signs -

no finger nose incoordination

no heel knee incoordination

gait is normal 

Investigations-