70 yr old Male with SOB

70 year old male with Shortness of Breath 

01/2/23

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.

K.Medha Reddy, intern 

Roll No: 61

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.

CASE:

A 70 yr old male, farmer by occupation from Nalgonda came to the hospital with chief complaints of:

Shortness of breath (Grade 3 MMRC) from 5-6 days

C/O cough with sputum since 4-5 days

C/O weakness of both UL and LL since 4-5 days

HOPI: 

patient was apparently assymptomatic 5-6 days ago, then he developed SOB since 5-6 days, GRADE 3 (even on walking for a short distance), relieved on rest. 

No H/O chest pain, palpitations, PND and orthopnea. 

C/O cough with sputum whitish in colour, since 4-5 days, increases at night.

No H/O cold, fever

C/O weakness of upper and lower limbs during shortness of breath 

No H/O tingling and numbness 

Past History:

K/C/O DM since 8 yrs on T. Metformin 500mg PO OD

K/C/O HTN since 4 yrs on T. Telmisartan 40mg PO OD

Personal history:

Family history:

General examination:

O/E: 

Pt is c/c/c

Temp: 97.3

PR: 107 BPM

BP: 160/90 mmHg 

RR: 28 CPM

General examination:

No pallor, icterus, cyanosis, clubbing, edema, lymphadenopathy.

Deformity of right great toe noted.

Hands: No stiffness, swelling or pain 

Systemic examination:

CVS: S1, S2 heard, no murmurs 

RS: B/L air entry present, 

Normal vesicular breath sounds

P/A: soft, non tender

Bowel sounds+

CNS: HMF+, NFND 

Diagnosis: 

Left sided pleural effusion with left side lung collapse 

? MTB with creatinine clearance 45ml/min ? CKD 

Investigations: 

RBS: 129

CUE: alb-trace; sugars-nil

Blood urea: 53

S. Creat: 1.5

Na+: 138

K+: 4.5

Cl-: 98

Hb: 13.6

TLC: 10,100

PLT: 2.20

LFT:

TB: 0.90

DB: 0.20

AST: 20

ALT: 16 

ALP: 246

TP: 6.4

ALB: 3.4

A/G: 1.12

Pleural sugar: 169

Pleural protein: 4.6

Pleural LDH : 152

Serum LDH: 207

Treatment: 

Therapeutic pleural tap done

Sup. Ascoryl LS 15ml TID 

Neb with Budecort 12th hrly/ Duolin 8th hrly

Inj. HAI SC TID

T. Nicardia 10mg STAT

On 2/2/23: 

FBS: 120

HbA1c: 6.8

Hb: 11.5

TLC: 9,400

PLT: 1.9

Pleural cytology report: 

Suggestive of inflammatory smear