67/M WITH SOB AND FEVER

11/06/23

Hi, I am shaik karishma , 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book 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 a diagnosis and treatment plan.

CHIEF COMPLAINTS : 

A 67 year old male barber by occupation, came to the opd with chief complaints of Shortness of breath since 1 week and Fever since 4-5 days

HOPI :

Pateint was asymptomatic 10 yearsback then he developed

Pain during micturation insidious in onset gradually progressive on a certain occasion he had a beer(750ml) & while micturating he noticed pressure pushing out some stone later which his pain diappeared

8 years back then he developed difficultly /Pain during walking(left knee pain followed by right knee) (used painkillers) ,following which he visited a hospital at miryalguda and treated with each intraarticular steroidal injections every year for which he observed decrease in knee pain 

6 years ago again he had pain during micturation ,visited Gandhi hospital and was diagnosed with renal caliculi. For which he was on medication 

3 months back he developed abdominal pain loin to groin type ,sudden onset there was increase pain and burning sensation during micturation -->visited miryalaguda hospital -->renal stenting

H/o Decresed renal ouput since 6 months 

15 days back his abdominal pain worsened , on &off left lumbar pain devleoped on eating non veg at a party 

 1 week ago he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital.

He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again.

C/o pain abdomen on &off left lumbar region since one week

C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents

C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling

C/o decrease in appetite since 1 week 

No c/o of chest pain , palpitations 

PAST HISTORY

He had history of hypertension since 10 years and on medication 

No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 

History of previous surgery Renal stunting 6 months back

Family history: Not significant

Treatment history: 

Renal Stenting 6 months back

PERSONEL HISTORY: 

Diet:mixed

Sleep:regular 

Appetite: decreased appetite since 1 month 

Bladder - decreased urine output with burning micturation since 1 month

Bowel movements are regular 

Addictions:he started taking chewable tobacco since 30 years and stopped one week back

He also had a history of taking alcohol since 25 years and stopped one year back

He started smoking (1beedi pack daily) 30 yrs ago later stopped smoking 22 years ago because of his elder son 

General examination:

Patient is conscious,cohorent , cooperative 

 well built and moderately nourish

Pallor present 

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent

Pedal edema :absent

VITALS:

TEMP:97.2F

PR:113bpm

RR:27cpm

BP:120/80mm hg

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (NVBS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)

CVS

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs

PER ABDOMEN

Shape of abdomen-scaphoid

Tenderness-No

Palpable mass-No

Liver- Not palpable

Spleen - Not palpable

Bowel sounds - Normal

INVESTIGATIONS