80 year old male with SOB,PAST CAD AND ?CAP

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.


 80 yr old came to casualty with chief complaints of SOB since 4 days 


HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YEARS BACK THEN HE HAD CHEST PAIN 

ECG FINDINGS SHOW ANTERIOR WALL MI AND RIGHT BUNDLE BRANCH BLOCK 

CABG AND STUNTING WAS DONE IN 2017 

H/O WEIGHT LOSS SINCE 4 MONTHS 

H/O LOSS OF APPETITE SINCE 4 MONTHS 

NO H/O RENAL CALCULI 

SINCE THEN PATIENT WAS ON TAB .ECOSPRIN AV 70/20 PO/OD 

TAB.MET XL 25 MG PO/OD 

SINCE 3 MONTHS BURNING MICTURITION , POLYURIA, INCREASED URINARY FREQUENCY 

?BOWEL AND BLADDER INCONTINENCE 

GENERALIZED WEAKNESS SINCE 3 MONTHS 

SOB SINCE 4 DAYS INITIALLY GRADE 3 PROGRESSED TO GRADE 4 

SINCE LAST NIGHT ASSOCIATED WITH ORTHOPNEA 

COUGH ASSOCIATED WITH SPUTUM ,CHILLS AND RIGOR 

NO CHEST PAIN, SWEATING,SYNCOPAL ATTACK , PALPITATIONS,GIDDINESS 

PAST HISTORY:

H/O SIMILAR COMPLAINTS IN THE PAST 

H/O BURNING MICTURITION 4 MONTHS BACK 

TREATED CONSERVATIVELY 

TREATMENT HISTORY 

DENOVO DM 

H/O CATARACT SURGERY B/L 6 MONTHS BACK 

CAD IN 2017 

PERSONAL HISTORY 


Appetite - decreased

Sleep - Disturbed 

Diet - Mixed 

Bowel and bladder - Irregular 

Addiction -  Present

         Alcohol : 90ml/day since 20 yrs

         Smoking : 1 pack/day since 20 yrs

He discontinued smoking and alcohol after his CABG. 

GENERAL EXAMINATION :


Patient is conscious , coherent, cooperative 

B/L mild pedal edema present




 No pallor, icterus , clubbing, cyanosis , lymphadenopathy, 

Temp : 99 F


Bp- 140/90mmhg

PR- 102bpm

RR- 20cpm

Spo2- 96% with 6lit o2

           85% at ra                                                                                           


SYSTEMIC EXAMINATION:

CVS : S1, S2 +,no murmurs 

ECG on day 1



ECG on day 9





RS : BAE + , b/l inspiratory crepts + at scapular, infrascapular region

P/A : soft , nontender 

CNS : No focal neurological deficit. 

INVESTIGATIONS:

Radiological investigation:






Sputum examination:

CBNAAT  was negative. 


Urine C/S



USG investigation:





PROVISIONAL DIAGNOSIS:

Community acquired pneumonia with cystitis with COPD with denovo DM2 with BPH with CAD S/P PTCA(2017)

TREATMENT:

Inj Piptaz 4.5gm iv tid d6

Neb with ipravent 6th hrly, budecort8th hrly, mucomist 8th hrly

Cpap intermittently

Inj lasix infusion @4ml/hr

Syp ascoril 10ml po tid

Tab ecospirin av (75/20) po hs

Tab metxl 50mg po od

Inj hai 4u - 4u -4u

     Nph 6u. - 6u. SC tid after informing grbs

Ivf 1NS 1RL @ 50ml/hr

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