65 yr old Male with SOB, Fever and Cough since 1 month

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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

CHIEF COMPLAINTS:

A 65 yr old male construction worker by occupation came with complaints of

      1.Fever and Yellowish discoloration of eyes since 1 month

      2.Cough & SOB since 1 month

      3.Burning micturition and abdominal pain since 15 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic until 1 month ago then had fever (high grade) with chills which is intermittent, no diurnal variation associated with burning micturition and  dark coloured urine and yellowish discoloration of eyes

H/o vomitings, loss of appetite , generalized weakness, weight loss of 3 kg since 1 month.

Few days later he developed cough which is productive with whitish sputum, thick consistency, mucoid associated SOB grade 2 and wheeze since 1 month aggravated on exposure to cold &dust.

After 15 days he developed abdominal pain and indigestion of food

PAST HISTORY:

He is known case of Asthma since 20 years

On inhaler Salbutamol 200mcg

N/k/c/o DM, HTN, TB, epilepsy

PERSONAL HISTORY:

Diet:Mixed

Appetite: Decreased

Sleep: Adequate

Bowel and bladder movements: Irregular

Patient consumes alcohol occasionally(2pegs) ,stopped since 1 month, consumes 4 -5 beedi per day since 40 years stopped 2 months back.

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative 

Moderately built and nourished 

Icterus present 

No Pallor ,Clubbing ,Cyanosis, Lymphadenopathy,Edema 

Vitals : 

PR : 76 bpm

BP : 130/80 mmHg 

RR : 20 CPM

Temperature : 98.4f

Spo2 : 98 % on RA

Vitiligo is present on Bilateral digital fingers and left anterior aspect of forearm

SYSTEMIC EXAMINATION:

Per Abdomen:

Inspection:

Shape - distended 

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations,scars,sinuses

Palpation:

All inspectory findings are confirmed 

No local rise of temperature

Abdomen is soft and tenderness is present in epigastrium

spleen and liver -not palpable 

No other palpable masses

Hernial orifice are free

Percussion:

Resonant 

Auscultation:

Bowel sounds heard

Respiratory system:

Upper respiratory tract - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- central

Palpation:

Trachea is central

Normal chest movements

Vocal fremitus is normal in all areas ( in sitting position)

Percussion: in sitting postion

                                        Rt.                   Lt

Supraclavicular. N(resonant).          N

Infraclavicular. N.                               N

Mammary region. N.                        N

Inframammary region. N.                N

Axillary region. N.                    N

Infra axillary region. N.                               N

Supra scapular region. N.                           N

Interscapular region. N.                              N.  

Infrascapular region. N.                               N

Auscultation:

Normal vesicular breath sounds

B/l fine crepts present in Mammary and Infra axillary region 

B/l Rhonchi in Intrascapular region,Mammary region

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins and scars 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

            Rt- UL. LL.          Lt- UL. LL

Bulk - normal 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 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Provisional diagnosis:

? Alcoholic Hepatitis 

?LRTI

Investigations:

ECG

Chest x ray

Usg: 

Review USG

2D Echo:

On 9/11:

On 11/11:

Treatment Given:

Inj.Optineuron 1 ampoule in 100 ml ns iv od

Tab.Amoxiclav 625 mg po bd

Tab.Udiliv 150 mg po bd

Syp.Lactulose 15 ml po tid

Neb duolin 6th hrly

Tab.pcm 650 mg po sos