Note - This is an a online e log book to discuss our patient's 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 centred 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.
Case sheet
Chief complaints
60yr old male came with
C/o cough ,cold since 3 days
C/o chest pain since yesterday night (5/1/24)
C/o fever since yesterday (5/1/24)
HOPI
pt was apparently asymptomatic 3 days back then he developed cough with sputum scanty in quantity,mucoid ,yellowish in colour,non blood tinged alw shortness of breath
a/w cold ,nasal blockage, no diurnal variatons
H/o fever -low grade , intermittent, not a/w chills and rigor
H/o chest pain - diffuse, squeezing type, aggravated with cough ,non relieving
H/o pedal edema since 2 yrs
H/o joint pains since 20yrs
No h/o nausea,vomitings,loose stools
No h/o abdominal pain
No h/o palpitations
No H/o headache , myalgias, arthralgias
PAST HISTORY
K/c/o Diabetes mellitus since 10 years
K/c/o Hypertension since 10 years
Not a k/c/o CAD ,CVA,thyroid disorders, epilepsy,asthma,TB
No h/o similar complaints in the past
TREATMENT HISTORY
Using unknown medication for DM,HTN since 10 years
PERSONAL HISTORY
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel - regular
Bladder - normal
Allergies- absent
Addiction -alcoholic since 35 yrs , occasional
Non smoker
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
Patient is conscious,coherent and cooperative
Heavily built and nourished
Pallor, icterus, cyanosis , clubbing, Lymphadenopathy -absent
Bilateral pedal edema present
Vitals :
PR : 104 bpm
BP : 110/80 mmHg
RR : 22CPM
Temperature : 100.8°F
Spo2 : 93% with 4 litres of O2
GRBS-301 mg/dl
Weight: 70 kgs
SYSTEMIC EXAMINATION
Respiratory system
Bilateral air entry+nt
B/L diffuse coarse crepts present
Cardiovascular system
Inspection:
Jvp not raised
Shape of chest - elliptical
No visible pulsations
No engorged veins and scars
Apical impulse not visible
Thrills-no
Cardiac sounds- s1s2 heard,No murmurs
Central nervous system
Level of consciousness-consious
Speech- normal
No signs of meningeal irritation.
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. 1+. 1+
Sensory system: intact
Co ordination is present
Gait is normal
No Cerebellar signs
Abdominal examination
P/A- obese ,soft ,nontender
Shape.of abdomen-obese
Tenderness- absent
Palpable mass -No
Hernial.orifices-normal
Free fluid - No
Bruits- No
Liver - Not palpable
Spleen- Not palpable
Bowel.sounds- heard
Investigations
HbA1c - 6.9
CUE -
Alb - +++
Sugar - +
Hemogram on 6/1/2024
Hemogram on 7/1/2024
Provisional diagnosis
? Community acquired pneumonia
? Acute worsening of Heart failure with midrange ejection fraction (EF - 42%)